Meeting

Virtual Roundtable: A Conversation on Food and Nutrition Policy With Francesco Branca

Monday, February 5, 2024
Speaker
Francesco Branca

Director of the Department of Nutrition and Food Safety, World Health Organization

Presider

Senior Fellow for Global Health, Council on Foreign Relations

FRIEDEN: Thank you so much for joining us. I'm delighted today that we have Dr. Francesco Branca with us for a conversation about nutritional issues very broadly. Francesco is Director of the Department of Nutrition and Food Safety at the World Health Organization in Geneva. And I can say that I've worked with Francesco for many years and found him to be always insightful, always constructive, and someone we can learn from and work with. So, I'm going to start with asking Francesco to make a set of general remarks, then I'll be discussing some of them with Francesco, then we'll open it up for conversation with all of the participants. Francesco over to you.

BRANCA: Well, thank you very much, Tom. And if I can say, I've been privileged to interact with you and with the organization Resolve to Save Lives that you chair. This has helped a lot in making headway in food and nutrition. And you realize—after my brief introduction—why I feel so. So, thank you for the partnership and thank you for inviting me to this very interesting conversation. I look forward to the interaction with the audience. I actually would like to start by giving my perspective on why food and nutrition are global challenges for health and development. And I think, you know, there are at least three reasons for that. 

And the first reason is the health reason. Really, all together, one third of the deaths and about half of the disability burden is accounted for by factors related to diet and nutrition. Unhealthy diets is accounting for eight million deaths every year, obesity: five million deaths, maternal and child malnutrition: three million deaths, and unsafe food for a hundred-thousand deaths every year. But this is probably an underestimate because food systems affect health through other pathways to production practices, for example, to the use of antimicrobials in in animal production, to the use of fertilizers and pesticides that have an impact on Earth through the environment to the health of food workers. So, it's really a much more comprehensive assessment that we should make on the of the impact of food system nutrition, and health. 

Then the second is the impact on the environment: twenty-five percent of greenhouse gas emissions, two thirds of freshwater use, over one third of Earth's landmass, the impact on biodiversity—as I said, the use of nitrogen and phosphorus fertilizers. So, it's a multiple set of impacts. And any economic impact of food system—and I just would like to say, and I'll put the link in the chat that just on Monday, yesterday, the report of the Food System Economic Commission has been released. And that report really gives an incredible description of the impacts, economic impact of food systems. And you know, the conclusion of the report is that the costs of the current food system are far larger than their contribution to the global prosperity. You know, the unaccounted cost of the burdens they place on people on the planet are currently estimated that fifteen trillion U.S. dollars a year, which is equivalent to twelve percent of GDP in 2020, which, by the way, is exactly the same figures as the expected turnover in the sector in 2030. So, you know, almost the same amount, you know, in terms of wealth and the same amount in terms of negative externalities. So only the health costs are eleven trillion US dollars. 

By the way, obesity on its own is four trillion dollars, three percent of GDP, plus the three million environmental costs. And then we know that actually food systems are related to poverty. In Europe, we're now seeing the rebellion of the farmers who see their income threatened by the global crisis and you know, the price it's paid on their food which is inadequate. So, you know, the small farmers are challenged, but then also the system is such that a healthy diet is unavailable and affordable to three billion people in the world. The trends are not encouraged, because, you know, unfortunately food insecurity and undernutrition is covering. The improvement with adding nutrition targets, particularly stunting, is been relatively good. But the balance between the decrease in undernutrition and any increase in obesity is not leaving us in a better situation in the future. 

What's been the policy response here? I was, together with colleagues in FAO, organizing the second international conference on nutrition back in 2012. And in that conference, we basically had the support of the global community on a series of targets, global nutrition targets, and noncommunicable disease targets that basically frame the narrative on food and nutrition in a much more comprehensive way. So it's not about as it used to be only about food insecurity. It's about a healthy diet. And it's about the prevention of noncommunicable diseases. 

And in that conference, there was a final document that was calling for a comprehensive multisectoral response on health systems, food system, trade, social protection. Sixty-two specific recommendations all evidence based, so there was a very clear picture as this as this has been implemented. Frankly, the answer is not really, not really. Even recently, when big initiative which has been launched by the Secretary General of the United Nation, UN Food System Summit, last year, we just had a two year follow up the stocktaking. It was a large mobilization, but very limited policy commitments all entirely voluntary, the UN Secretary General call to action of this last stocktaking is very much open ended. It says you need to think about the food system. It's important for sustainable development, you need to engage all sectors and stakeholders, you need to invest in innovation and technology. You need to engage with business. But yeah, very general call to action. 

COP28 was quite interesting. It's—the concept of sustainable healthy diets has been mentioned in the health declaration and the food declaration spoke about the impact of climate change on food production, but it really did not commit to any food system transformation. Now, the Food System Economic Commission estimates that two hundred to five hundred billion U.S. dollars a year are needed to transform, radically, the food system, but the benefits would be five trillion U.S. dollars a year. Going specifically on the specific issues: obesity. 

Obesity, I mean, basically, the trend has been going up. You know, very few countries have been able to make a change. We've seen some change in some European countries in some sub areas, maybe regional changes, even actually, the United States has been some communities that have shown some change, but largely the change has not been there. The policy response has been inadequate. And the World Health Assembly asked WHO to do something about it. We developed what we called an acceleration plan, basically saying yes, obesity is complex. But can you do at least five things which we know are cost effective? Can you establish taxation of sugar sweetened beverages can you have warning labels to inform consumers that they should, you know, prefer certain products to others? Can you stop marketing for—to children? Can you have healthy public food procurements, physical activity in schools, and integrated health services in primary healthcare that understand the issue of obesity? So, these are fairly basic things. And thirty-one front-runner countries have responded to that. But you know, fifteen countries have committed to establish as a sugar taxation but you know, in a sense it’s a drop in an ocean yet. 

Early nutrition, early nutrition. We know that early nutrition is good for the prevention of undernutrition and the prevention of obesity. And we've done well in improving breastfeeding rates, ten percentage points in the last ten years. But you know, code-of-marketing breast milk substitutes, only thirty-seven countries are implementing it entirely. Maternity protection law is not implemented. Baby-friendly hospitals, you know, how many hospitals are really done in a way that, really, breastfeeding is supported by adequate—adequately training health care workers. 

For the environment, you know, the kind of policies that would make the food environment more conducive to healthy diet support is still, you know, a lower number of countries and also the well-known ways to deliver those problems are not implemented. For example, sugar taxation, no taxation of sugar sweetened beverages, yes, many countries do it, I think we have about eighty countries doing it. But you know, how many really have, you know, the taxation at the level which we know is going to produce an impact? Front-of-the-pack label, in Latin America, we have this warning symbols, which have shown to be effective in shaping consumer choices, but you know, others, other countries and other regions in the world, Europe, Australia, U.S.—scoring systems, which do not have the same impact. 

And then finally, finally, you know, what we've been really working with, with Tom and his colleagues—the reformulation of process food—that's an area, but actually some remarkable impact has been demonstrated. Trans-fat, we now have forty-six percent of the world population is covered by policies that, you know, eliminate this compound, you know, which is industrially produced, industrial trans-fat, you know, for all the population. In the Americas—it’s actually this is even better. America is about to be declared trans-fat-free: eighty-five percent of the population seems to be covered. And you know, this change going in, you know, in only a few years—from six percent to forty-six percent coverage—has saved a hundred and eighty-five thousand lives. So, it's remarkable what you can do. 

But also, you know, for example, very limited success. There are clear benchmarks, we know what, how much sodium should be in processed food, many countries, actually, in many countries, the intake of sodium mainly comes from processed foods. So, changing the content of salt in processed food would produce enormous benefits. Industry has not been willing to commit to changes. And again, the regulations there, the regulatory environment is not really making the change. 

So just to conclude, basically, the challenges are enormous. The reasons to make the change are there, the solutions are there, but the policy commitment is not there. Can you speculate? Is it because of commercial interest? It’s because of you know, you know, capacity issue, and you know, capacity to develop? It's a complex system and food systems are complex. It's a capacity to really develop the right measures? Now we can discuss it, but the fact of the matter is that the action taken has not been sufficient. That's why we are in this situation. Thank you. Back to you, Tom.

FRIEDEN: Thank you so much, Francesco. That was a whirlwind tour through the world of, of nutrition policy and where we are as a country, as a world, as a community. What I'm going to do is, I'm going to ask a few questions, and then in about fifteen minutes, we'll open it up for questions from any participant. Let's start with the good news. There are areas of progress that—you mentioned trans-fat for one—you mentioned, the Latin America front-of-pack warnings for another, in other contexts. And you mentioned also baby-friendly hospitals and a steady increase in breastfeeding. So, what can we learn from those successes? What can we learn from that progress? What are success factors that may be able to be applied to make further progress there, and also to extend that progress to some of the areas that are making less progress?

BRANCA: So, I would say, first of all, you know, a good description of the issue, of the challenge with data. I think data are really important to understand, you know, what is what is the burden—health burden. We need to understand what is happening in the food system. So, for example, what is the content of these different compounds in food, so you know, good knowledge of the space. 

Second is science. Contribution of science that has designed programs in a way that we could demonstrate effectiveness. I think that's important to convince that a certain measure, you know, may have a cost and we're able to assess the ratio of cost effectiveness. And that is important to persuade policymakers. 

Third, a clarity about how to implement these things. So, you know, the trans-fat elimination, we need to understand exactly the different elements in the process, we need to see where the measures are needed. And we need to see—understand who the stakeholders are. So, for example, in the, for the trans-fat, it was really critical to have, this—what we call the replace package. So, a series of, you know, policy briefs in which we say, okay, this is how you do the monitoring, this is how you engage with the stakeholders, this is how you communicate. So, clarity about the measures. 

And then really, probably one of the most important is generating the consensus. Generating the consensus, which requires civil society, media engagement, even for difficult agendas. Just to give an example, meet some of the warning, but you know, even before that, the taxation of sugar sweetened beverages in Mexico. That could only be done because of the deep involvement of civil society, you know, the organization called El Poder del Consumidor, or the Institute of Public Health in Mexico. And these people risked their lives, I mean, they were personally challenged. So, you need a very energetic civil society, of course, supported by UN organization. So, you know, creating basically a social movement around those measures. I think these are the success stories. For breastfeeding, definitely the—this is also the case, but you know, having a broad movement, including the people who are involved, including, you know, the mothers, including the health workers, so that has created the consensus that led to the adoption of defective—of defective laws.

FRIEDEN: Great, very helpful. So, what I heard was technical, proven policies, pocketbook argument, money, clarity on how to implement, a social movement with partnership between civil society and government. And you also mentioned the importance of individuals willing to step up. I think in Chile, which had the first front-of-pack warning, it was perhaps one legislator who pushed for it year after year. Can you say anything more about how that kind of partnership between government and civil society can be most effective—where it's worked well and where there have been problems? You've mentioned in the past the breastfeeding movement, where there's possibility with synergy that wouldn't be there otherwise.

BRANCA: I mean, I think in Chile is a good example. And personal leadership is important to me, definitely I mean in Chile, the fact that we had basically a member of parliament, the head of the Health Commission, who worked you know, in a sense in a bipartisan way that was that was really important. I mean, other good examples in the breastfeeding space has been when you know, ministers, female ministers themselves had gone through the understanding of the issue and you know, that was helping in the political commitment. It didn't work well when they were interferences—largely I would say. And then when these interferences were not overcome by adequate responses. 

We still have countries who are reluctant to take on some of these measures because they have been threatened by some commercial entities who have said okay, we will withdraw our foreign investment—foreign direct investment in countries and trade agreements have been often the cause for the rapid evolution of the food system towards unhealthy food environments. And even if policies could be effective, there are interferences that try to undermine them and try to challenge the evidence base and okay, you know, if you establish a taxation of sugar sweetened beverages, there will be a reduction in the workforce. Or you know, there will be—if you put front-of-the-pack labels it will actually affect your trade and you might be challenged by the World Trade Organization. 

Specific countries trying to establish restrictions on to the import of certain products, high in fat, challenge the index again, you know, on the trade basis. Even the current guidance that WHO has produced on digital marketing breastmilk substitute is challenged on the ground that, you know this violates certain trade laws in certain countries. So, I would say that, you know, the competing vested interests, that is the main cause. 

But we can respond to that. I mean, we have developed a series of policy briefs, for example, on sugar taxation saying, okay, are these arguments, you know, solid? In reality, you know, there's no evidence that the establishment of taxation of sugar sweetened beverages has had any effect on employment rates. Trade laws, are they really broken? No. And you know, there are ways for of course, countries to establish import restriction, if these restrictions are also imposed on their own products, and they do not, you know, create—basically violate the competition rules of the World Trade Organization, so that it can be done so. So, there are misconceptions that are—that can be—that can be explained and deconstructed.

FRIEDEN: Well, you've anticipated and answered my next question, which is, what are the main barriers to progress? And what can we do about them? How about—you talked about the science being clear as one of the success factors when it comes to obesity or sodium or some of the other nutritional factors, is there too much scientific doubt? Has that been something that has made it more difficult to act or is that just something that commercial interests exploit to delay progress?

BRANCA: So, I mean, I admit that we've been able to consolidate the science relatively recently. So, when I started my job about fifteen years ago, we had some suggestions that you could go in certain directions, but then what happened? Some countries, because you know, you need, of course, it's important to have some pilot studies. We learned a lot from taxation of sugar sweetened beverages, because in U.S. cities, there were some experiments like that. Even in colleges—only in colleges, we could use that. But then what happened is that some countries basically had the courage to establish national policies. At that point, we had, you know, the information to be able to bring together the science. So, the science has been consolidating recently. So, you know, only last year, we've been able to update the, what we call the best buys for non-communicable diseases. And now we have a package of food measures for food and nutrition, which we didn't have before. And we can now prove they are cost effective. So, the science has been evolving, you know. 

Also, our capacity to monitor policies has evolved. You know, in WHO we keep a database called the Global Database on the Implementation of Nutrition Action, which is, you know, several thousand document there. So, we have a good understanding of what is the policy space. So, all that understanding is contributing to make the case. So, the science is still challenged, of course, still challenged because we are not able to have the same level of certainty in analyzing policies, then when we do a randomized control trial. I mean, WHO has decided to develop guidance on policies. And so, we have last year we released guidance on marketing food to children, giving clear recommendation about regulating. You know, in the past, when member states had to agree on WHO whose policies, they were saying, well, you know, we recommend to do something, but it can be voluntary. Now, with our scientific analysis, you say, no, sorry, voluntary, we have the evidence, it's not effective. You're not going to be able to achieve that. So, you need to have regulation. So, that’s with the marketing policies. 

We're about to release also a guidance, guideline on taxation of sugar sweetened beverages, another one on labeling, another one on public procurement of food. But in some cases, you know, the way we analyze the science as well actually the evidence is moderate quality, because you know, the nature of the evidence because you know, when you analyze, you know, these policy cases, you know, you cannot have a control, for example. And the kind of data we have, you know, could be somehow considered to be partially biased. But elsewhere, I think we're getting better, and also evaluating the policies. And whenever, you know, countries set up policies, we ask them to make a good, you know, to set up a good evaluation system, because that will benefit everybody else.

FRIEDEN: One of the hot topics is ultra-processed food. You have in Latin America, a big focus on trying to reduce consumption of ultra processed food, you have some debate about what the definition is. What's your take on this topic?

BRANCA: So, I must say that we have been discussing this, and at the moment, WHO doesn't use the term ultra-processed food. We prefer to say highly-processed, because, you know, we consider this as an important element, but we don't want to be at the moment seen as fully sponsoring the concept of ultra-processed food which is based on a specific classification, which is the NOVA classification. It's a very interesting concept and we believe it's important because it doesn't only bring together the—and actually make it much more scientific than what we used to call junk food now, makes it much more objective—doesn't only refer to the nutrition composition of these foods. You know, high-fat and sugar, so that is what they used to say in the past. Yes, that's, that's some characteristics of these foods. But there's another component and that’s the component of the, of the disruption of the of the original food matrix. You know, having an impact on absorption of nutrients, and creating something which, you know, has been demonstrated by many studies, very important, which is addiction. 

Addiction, so addictive behaviors, would, in a sense, make this kind of food similar to what has happened with tobacco. So, in a sense that, then that leads out the argument, it's actually these foods have been chosen freely by individuals. No. They have been pushed on people who then have become addicted to them, and then, you know, it’s beyond their control. So that requires some form of control limitation. So that's an interesting, you know—plus the other component of the food which make them appealing, you know, which also contributing to their addictive power, you know, the use of certain additives, the use of certain—that, you know, for example, make them more appealing from the appearance point of view, the packaging may be improving the convenience. But, you know, how do we define all these elements in a more rigorous way? And above all, you know, how can we act on them. 

So, the definition is absolutely critical to be able to define response measures. So, it is our intention to do more work on this, and to build on the excellent work which is now being done by many scientists all over the world. Now, starting from Latin America, but really covering, you know, many parts of the world. You know, I've just seen a report that we have done in the Asian region, you know, describing how they had the highly processed food, really have, you know, taken up and they are rapidly spreading in that part of the work, which already has an incredible problem of non-communicable diseases.

FRIEDEN: If I'm understanding you correctly, what you're saying is: perhaps we should be thinking not so much about ultra-processed or highly-processed, but highly addictive food, which may then require a different approach.

BRANCA: Possibly, but, you know, we need again—there are ways to do that, and there's this very good science about how to measure effectiveness, but, you know, I think the challenge there is the—is the definition and currently in the definition of ultra-processed foods, there are gray areas. You know, the interpretation in different parts of the world may be different. So, if we are able to do that, yes, I think you know, if we're able to come with a series of, you know, characteristics of the foods which have finally, a negative health impacts and define them then we can define a response strategy much more, much more effective.

FRIEDEN: Great. Now, we can just turn to the CFR colleagues to outline how people can ask questions.

OPERATOR: Absolutely. [Gives queuing instructions.] Thank you, Tom.

FRIEDEN: Thank you very much. Let's delve a little bit more deeply into the issue of addictiveness. Is this the new frontier for how we should think about what should be regulated? Is it all about sugar sweetened fat? Is it all about increasing tolerance and increasing consumption? Is this an area where there's possible policy progress?

BRANCA: I mean, definitely, sugar is a nutrient we should try to tackle much more effectively. The exposure to sugar unnecessarily starts from early in life, starts from you know, foods that are designed for children. And then it stays on and then we have ample opportunities to consume much more than what WHO recommends, which is maximum ten percent of energy from sugars, which, you know, if you translate it in a drink is probably less than one can of soda per day, you know. And then you don't eat anything, any sugar, any anything else than that. So, sugar is definitely important. And sugar, the way it's actually consumed through highly processed food can be responsible for an effect—a neurological neurobiological effects, there are demonstrated mechanism that then can lead to that reward mechanisms, for people look for that, and that's actually the starts of the addiction phase. So probably, that would be one of the nutrients to focus on. We say that, you know, we need to have healthy diets and we need to consume whole grains, for example. So similar to sugar could be refined carbohydrates, which could have a similar mechanism of action. So that's where I would say that we have to start. 

The other important nutrient of course is sodium. Sodium is actually the number one killer. If you look at that number, I gave you eight million deaths every year from unhealthy diet, and then you say, okay, which other components of unhealthy diet you're looking at, then you have sodium—excess sodium, which is number one—then you have a number of insufficient intakes. So, you have insufficient intakes of whole grains, fruit, vegetable, legumes, and then you have high intake of fat, trans fat, red meat. So, sodium is the one we have—and of course, you know, sugars. So, sodium is the one nutrient we have to address together with sugar if we really want to, you know, make a big change in people's health.

FRIEDEN: Great, now we've got some questions from the group. Let me start with Valentina Barbacci. You can—you can speak.

Q: Yes, wonderful. Thank you. Can you hear me now? Wonderful. Valentina Barbacci, based in London here, Term Member at CFR but also based with CEN-ESG. I'd be grateful for your thoughts with regards to the impact of endocrine disruptors and hormone blockers that are increasingly showing up in various you know, not just food, it's also baby products, you know, hygiene products, all sorts of things that are from—range from adult to infant care products. So, it's also in foods but predominantly in health care products as well—sorry: self-care products. And what can be done to bring on sort of voluntary disclosure directives that might then eventually lead to mandated disclosures, much like we've seen with TCFD and TNFD mandating climate and biodiversity disclosures that were initially voluntary, but have now become—or are becoming—mandated so that this kind of tip the—tip the curve a bit and perhaps that we could see something in the health side with regard to that? Maybe I'm naive and optimistic, though I welcome your thoughts.

BRANCA: No, I think you're right. It's a very important topic. When we’ve been looking at obesity, we've been trying to be thorough, and really look at many different outcomes, including endocrine disrupters. It is a possible mechanism. Of course, it's an important mechanism also for other for other aspects. But for obesity, we didn't really find a major role in endocrine disruptors. Definitely the endocrine disruptors have a much greater role for other aspects of health, including reproductive health. 

So, from the food point of view, you're quite right, you know, we would need to look at it more carefully. I think in Europe, there's been much more experience—there have been some interesting reports. So, I think it's been looked at more carefully. I think we are, we're not ready with that. I think we need to do much more work to be able to describe the issue. And then maybe come up with some recommendations. But it's on—you can imagine, you know, the list of things we need to look at, it's very broad food system is very broad. Endocrine disrupters is definitely one of them. It's a large category of products. It includes some products, which are already regulated, you know, such as some pesticide plus other products which are not regulated. So, you know, thank you for reminding me that but you know, I think we are only partially able to respond to them.

FRIEDEN: Next is Joel Cohen.

Q: Thank you for this excellent presentation, Mr. Branca. My name is Joel Cohen. I'm a professor at the Rockefeller University and Columbia University in New York City. I'd like to ask your views on dealing with childhood stunting. Approximately a hundred and fifty million children under the age of five are stunted due to chronic undernutrition and infection. That's twenty-two percent of all the world's children. At the same time, according to FAO, the world produced 2.8 billion metric tons of cereal grains last year. At four to five people per metric ton, that is sufficient to feed adequately the calories required by eleven to fourteen billion people. We have a population of eight billion people. And yet twenty-two percent of all the children are chronically undernourished. And the reason is that only forty-three percent of the cereal grains go into the mouths of people and the other fifty-seven percent go into animals and machines. I am worried about the future of our species. And by the wastage of one fifth to one quarter of our potential problem solvers by starving their brains in childhood. Could you help me understand what would be the most effective steps to dealing with this problem? Thank you.

BRANCA: Well, thank you, Professor Cohen, this is a wonderful question. And you got all the numbers, right. And those are very compelling numbers indeed. So, when WHO suggested global nutrition targets to the World Health Assembly, we had stunting, you know, in as the first one. And, you know, 2012, the target was to reduce by thirty percent the number of stunted children by the year 2025. And since then, there has been actually a good reduction. But some countries, particularly the countries in Africa or in Latin America, have been successful in making progress towards these targets. South Asia, unfortunately, has been not able to respond, at the moment actually, the largest number of children with other stunting and wasting is in South Asia. So that's where the biggest part of the problem is. 

Stunting is not only a food issue, stunting is a combination of issues—is about access to health and health care. It’s about clean water, it’s about adequate care by caregivers. So, there's been a reduction of stunting, because of the improvement in food security, or health care in some parts of the world, but not in other parts of the world. We're not going to achieve the 2025 targets, unfortunately. COVID made things worse. So, you know, if we have a curve of reduction, that curve actually flattened, and we had many more children who didn't stop their progression to stunting. Because, you know, food insecurity hit, families were economically hit, the services were stopped, immunization decreased. So, all of that affected stunting. 

In terms of food, I think what is important to remember is that I think you've made a, you know, incredible calculation of the energy side, it's actually not just the energy side, it has to be nutritious food. It has to be access to plant food, but also some animal source foods, which, you know, a small amount of animal source foods are critical—doesn't have to be meat, it can be eggs, it can be dairy, in some parts of the world, it can be insects—that needs to be part of the diet of stunted children. 

We have, unfortunately, big problem of the variety of food that children eat. We have an indicator called the Minimum Dietary Diversity, and you know, you can really see there's a correlation between those stunting rates and having diets which are very little diversified, you know, almost, you know, a couple of items only per day, per child. And then you have the combination of wasting and stunting. So, there are crises that generate acute malnutrition, and then repeated acute malnutrition crises are going to increase the problem of stunting. 

So, in a nutshell, you know, the response can be there, I think there's quite some investment done by countries themselves. I mean, we've seen many more countries that are home to these stunted children also scaling up a response so that—that's good news. But South Asia still has a lot to do. I mean, Indian government has set up an important program to address the stunting of children. It's about social protection. So, we need to have much stronger social protection system. Pakistan had a very good social protection system, for example. I think India is the same in some states, but it needs to scale up. So, you know, probably it's not only a food security issue, but it's a combination of actions that governments should take.

FRIEDEN: Francesco, I've heard a calculation or an assertion that each episode of gastroenteritis in a developing child—in a young child sets them back a few months on their growth curve. And I think this is the point you were making, that it's not just about calories in, it's also about clean water and vaccination and health care.

BRANCA: Oh, yeah, absolutely. Actually, you know, this is something that we in nutrition, learned, you know, in our 101. There was a famous study done in Guatemala, by a gentleman called Leonardo Mata. It's a beautiful book he has written and basically was looking at, you know, the weight and the height of children longitudinally. And you could see that, you know, these children had, you know, the growth curve was, you know, like, like stairs. And then, you know, the ideal curve is like this, and then, you know, they were progressively, you know, detaching, you know, you know, they have this infection here, and then, you know, they have, you know, the poor season there, and then progressive is like that. So, absolutely, I don't remember exactly the mathematics there. But you know, it's something that happens progressively also because of a degraded environment. 

We're going to see more of this because of the climate change, because climate change is going to have you know, even greater problems to the quality of water to the accessibility of water, you know, plus the seasonality of food which is going to become worse. So yeah, we need to have a much greater investment if we want to really you know, bring down the number of stunted children, and I totally agree with the previous speaker that this is something which is completely unacceptable from moral—but also, you know, this is the future of our society. And we use this phrase we need to make investment to—in brain infrastructure. I mean this is this is the future of the world and of society so, societies will fail if they don't address the standing issue. Professor Cohen, thank you.

FRIEDEN: Thank you, let's, let's spend a minute on the front-of-pack warning that was really piloted in Latin America, it has now spread to most of the continent or much of the continent. What's your take on how impactful that will be and how we can get other parts of the world to take that up? Europe has gone a different route, as you indicated its route that's not likely to have the same impact, can that be changed? In the U.S., I'm afraid the current Supreme Court might preclude this type of activity. It's problematic from a current legal interpretation. Corporations apparently have the same rights as people in the U.S., and it's considered compelled speech, so, it would be a violation according to the current legal regime of the First Amendment. I don't think a different reading of the of the law would have supported that, but it's probably out of the question in the U.S. in the foreseeable future. But globally, what's the potential for geographic expansion? How can we get there, and how important is it?

BRANCA: So first, maybe the impact and we're looking at data. And we need to see data. I have seen some very interesting data from Chile, I believe, that are demonstrating that actually, the impact of warning on the consumption, for example, on sugar sweetened beverages was about twenty-six percent. So even more than the taxation of sugar sweetened beverages. So, you know, it seems that it has an impact on purchasing choices of people. It's quite interesting, because, you know, the wording are simple. And everybody understands them, including young children. So that's, that's, I think it's incredible power of persuasion. So, so that seems to be good. Is it going to have eventually an impact on the overall change in the diet? That's something to be seen. So we still do not have data to say, okay, this, this has, for example, reduced obesity rates. We don't, but probably because we, we need to have a combination a package of policies, but definitely warning labels may be an important measure to take. Also, because it might for example, help on some of the difficult actions, which is the sodium reduction. So, labeling has always had a good impact on sodium reduction.

So, we, we should be able to say they work and we're collecting data now in the many countries in Latin America that are doing it, it's actually not just South America. Israel has done this; Canada has introduced a similar—not exactly the same but in a similar scheme. So, we need to see what happens there. 

Now can this expand? Other parts of the world are using different systems so rather than saying you know, you shouldn't—you're discouraging this particular food because it has too much I too much fat, sugar, salt, we're saying okay, this is a food and you know, overall, the combination of its characteristics make—places it into a favorable or disfavor category you know. For example, France has developed called the Nutri-Score system, which is a great from A to E. A being, you know, the green one or the one which is sort of favorable, you can eat basically, you know, as much as you like. E is the is the category in red, which is discouraged. So, that somehow is an advice to moderate consumption of the categories in the E or in the higher is scoring. A similar system is the one used in in Australia, New Zealand: the five-star system. 

In reality, you know, if the outcome is the decrease in consumption of an item, the warning seems to be more effective than other scoring systems. As you say, there are challenges there, definitely the warning system is fought very, very strongly from—by the corporation, and you know, because this indeed affects their choice capacity. The warning symbols are also used to connect to other policies. So, for example, you know, products with the warning symbols cannot be distributed in schools, or products where the warning symbols cannot be marketed. And so, basically, you know, this system allows a combination of policies, which are shaping people's choices. So that's, I think that's the secret of its effectiveness.

 I think, you know, if we're able to demonstrate its impact, it's something that has a future. I have something quite interesting from a colleague studying the addiction of—to foods. And that is the fact that I think the argument for having legislation against tobacco in the U.S. is exactly the argument on addiction. So that goes beyond, you know, that maybe could be a way to respond to the issue of the freedom of speech, something that, you know, affects you beyond your choice should be discouraged by public policy.

FRIEDEN: If only public policy were so rational in the U.S. We have time for one more question, if there's any question from the group. Meanwhile, let me ask you about the kind of best-case countries. Are there countries where you think there's a real possibility that we will substantially reduce sodium intake or turn around the obesity epidemic, because we don't have great success stories? We've seen in in various areas—Denmark, taking the lead on trans-fat, Chile on the front-of-pack warnings—but in terms of actual impact on some of these really difficult problems, we haven't seen any countries stepping up and achieving that kind of outcome. Do you see what the ingredients might be, or which countries might be most likely to succeed or to at least undertake the effort?

BRANCA: I'd like to be optimistic. I mean, we have learned from countries. I mean, the whole nutritional epidemiology has been developed based on the case of Finland many years ago, who reduced dramatically the intake of saturated fat. I mean, they were dying of cardiovascular disease, you know, more than anybody, anybody else in the world. And it was changed, and it was a lot of change in the food system. It can be done. Finland was also good at reducing sodium intakes with a combination of policies, particularly the labeling, but you know, negotiation with the company's public food procurements. Now, the UK has done some interesting work, at least they brought down a couple of grams. Nobody has really achieved the WHO recommendation of five grams per day, but many countries have brought down the levels of consumption to nine grams, you know, from very high levels. So that's, I think, already good news.

But there are others who are promising. I was talking to my colleagues in Washington about Colombia. Colombia has very tight benchmarks for sodium in foods, and they now have introduced a food taxation law that actually might target those foods. So, Colombia is an interesting one, for sodium. For obesity. We're really, you know, all you know, looking into what—looking forward to what Chile is going to tell us about childhood obesity. They've really done very good things, very, very effective. Portugal is an interesting country. They have also introduced taxation of sugar sweetened beverages, reduction of marketing for—to children. And you know, I've seen data—I mean, I always want to see maybe two rounds of surveys, but you know, the first round of surveys you know, there's an obesity surveillance initiative in Europe. And you know, Portuguese children seem to be less obese than they used to be before. So that's good news. So, I think we need to keep pushing, we need to keep collecting the data. We need to keep looking for advocates. And, you know, I want to be, I want to be a bit more optimistic.

FRIEDEN: Great, thank you. We're almost at time. But we have a quick question again from Valentina Barbacci. Very briefly, please.

Q: I’ll make it super quick, I just love this topic. Could you speak to a little bit—regarding the studies that you found in other countries—could you speak to the environment and Tom, you mentioned the U.S. environment—legal environment—but the research environment whereby studies that aren't tied to drugs or drug resolutions are not funded? But we seem to have very good examples of studies elsewhere in other countries. And so how can we raise the profile about that—you mentioned obviously support, but could there be other investment that goes into funding those studies on a larger scale to support further rounds of data? And would it be a philanthropic model? Would it be another type of model that you would recommend, something that doesn't, you know, corrupt—corrupt, the studies itself, as we often see now, and it can be tragic when that happens?

BRANCA: You have a very important point. Because we have a challenge actually in finding the resources to address—in general non communicable diseases—but now these aspects of nutrition? I think we have to rely on philanthropists. I think Bloomberg Philanthropies has been absolutely instrumental to what is happening in Central and South America. Supporting civil society, supporting independent academic research; I think that that's a model we have to we have to still rely on. Potentially, there are other ways to do that. And I think Europe has some good independent research. The European Union has funded seventy-five million of a joint action bringing together thirty countries on the prevention of non-communicable diseases, it’s exactly targeting the good practice for policies. So, philanthropists, and, you know, large funding institutions, which of course, are government related. That's what we need.

FRIEDEN: Great, well we're just about a time. We heard exciting things from Francesco about a clear way forward on obesity with taxation of sugar sweetened beverages, clear warning labels that will discourage consumption, stop marketing food to children—and I would say maybe not just children, but marketing, unhealthy food, generally—healthy public food procurement policies, promotion of physical activities in schools; that the best buys have been updated. There's an economic case to make, there's technical clarity. Certainly, we always need to know more, but there's much that we can do with what we know now. Francesco, I'll give you the last word, is there anything more you'd like to say or last words of wisdom on healthy eating for long, healthy, productive lives?

BRANCA: Well first of all, thank you very much for this opportunity for the very stimulating questions. I’ll think more of what we can do about endocrine disruptors, but what is most important is the fact that this kind of conversation and having a community which is—we keep thinking is really important. So, looking forward to your reflections on this. From my side, I must say that we will be going further in creating also collaborations and bringing together the countries who are willing to work together. We have what we call the action networks. So, bringing—coming together to help each other or making better action and then I think that the success will encourage us to go even further.

FRIEDEN: Great, thank you very much and back to CFR to close us out. Thank you so much Francesco. And thanks to the group for joining and great questions. We look forward to validating the optimism you feel that we will make real progress making our food environment healthier. Certainly, the link you sent in the comments you made at the outset made clear how much is at stake in our health, in our economy and in our environment. Thank you all so very much.

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