Policy and Position Statements

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Healthy Eating Position Statement

Chronic diseases are now the leading causes of morbidity and mortality in the United States. They are also the primary drivers of healthcare expenditures. Currently, over one third of adults in the United States are obese.1 Obesity and unhealthy diets are also major contributors to chronic diseases like diabetes, cancer, hypertension, and heart disease. The environments we live in contribute to unhealthy eating, as it is difficult to make healthy choices if there is a lack of available healthy foods. Social determinants of health, including economic and social conditions such as poverty, also influence access to healthy foods and health of populations. In the U.S., over 23 million people live in "food deserts" - low-income neighborhoods that are more than one mile from a supermarket or large grocery store.2 Oftentimes, lower income neighborhoods also have limited healthy foods choices and instead tend to have fast-food restaurants and other unhealthy, inexpensive food choices. Policies regulating sodium, trans fat, menu labeling, added sugars, and food marketing make it easier for individuals to make healthy decisions about the food they consume, and reduce harmful food additives.

ASTHO supports state and territorial health agencies' actions to address the availability of healthy foods, change the culture in the United States to promote healthier lifestyles, and make the healthy choice the easy choice for everyone. National and federal strategies such as the Dietary Guidelines for Americans, National Prevention Strategy, and the Institute of Medicine's Accelerating Progress in Obesity Prevention Report serve as a roadmap for state health agencies to address healthy eating living policies and programs across various sectors.3,4 Programs, such as the Preventive Health and Health Services Block Grant and Coordinated Chronic Disease Programs, can provide the funding and infrastructure needed to support healthy and safe communities with access to healthy foods for all populations. Communities where individuals feel safe from the threat of injury and violence empowers them to make choices that allow them to better prevent or manage chronic disease.

Sodium Reduction
Heart disease and stroke are the first and third leading causes of death in the United States, respectively. High blood pressure leads to more than half of all heart attacks and strokes. Only one in 10 American adults consumes an amount of sodium within the recommended limits, and many consume more than double the recommended daily limit for sodium.5 Higher consumption of salt, along with age, obesity, and family history, leads to higher blood pressure. The age-adjusted prevalence of high blood pressure is nearly 50 percent greater among African Americans than the rest of the population.6 The Dietary Guidelines for Americans 2010 (DGA 2010), states that the major source of excess dietary sodium is the consumption of processed foods.7 Reducing sodium levels in packaged foods and restaurant foods by half would likely result in a 20 percent reduction in the prevalence of hypertension and 150,000 fewer deaths.8

Trans Fat Regulations
Artificial trans fatty acids (trans fat) is the most harmful fat in the food supply. It is linked to about 50,000 fatal heart attacks annually and may also increase the risk for diabetes.9 In November 2013, the FDA issued a preliminary determination that partially hydrogenated oils, the primary dietary source of trans fat in processed foods, are not "generally recognized as safe" for use in food.10 Currently, California is the only state that has enacted a law banning the use of artificial trans fat in restaurants.11 In addition, Delaware and Colorado have passed laws prohibiting the use of artificial trans fat in foods served in state public schools. A number of cities and counties have also passed laws eliminating trans fat from restaurants.12 

Added Sugars
In 2010, added sugars made up at least 10 percent of daily caloric intake for the majority of U.S. adults.13 Excessive consumption of sugars is linked to obesity and lower intake of essential nutrients.14 There is also a relationship between consumption of added sugars and cardiovascular disease risk in adults.15 Sugar-sweetened beverages are the primary source of added sugars in U.S. diets.16 Children and adolescents consume an average of 365 calories per day from added sugars, with an average of 173 calories per day from sugar-sweetened beverages (soda and sugary fruit drinks).17 Data points to the healthiest drinks being water and unflavored, low-fat milk.

Menu Labeling
Menu labeling provides critical information to consumers so that they can make decisions about the foods they eat. Americans spend almost half of their food dollars at restaurants and eat about a third of their calories away from home.18 Approximately half of chain restaurants do not provide any nutrition information about their foods to their customers.19 Consumers cannot make informed choices about what to order in a restaurant unless they have adequate information about what they are choosing. Most Americans support menu labeling for nutritional information such as calories, fat, sugar, and salt content.20 Menu labeling can also lead to product reformulation as manufacturers compete to meet the demands of health-conscious consumers. In 2014, the FDA issued new proposed changes to the nutrition facts label on packaged foods, including the addition of information about added sugars, and updated serving sizes and daily values for nutrients.21 

Food Marketing
In 2012, nearly one in five children aged 6-11 years in the United States were obese.22 A contributor to the epidemic of childhood obesity is marketing of unhealthy foods to children. Children in the U.S. view an average of 2.8-4.8 fast food ads on television every day.23 The foods most frequently marketed to children are unhealthy. One study found that 98% of food advertisements viewed by children are high in fat, sugar, or sodium.24 Communities of racial and ethnic minorities also experience higher rates of targeted marketing of less nutrition foods. Outdoor advertisements featuring foods of low nutritional value are 13 times denser in predominantly African American neighborhoods and nine times the density in Latino neighborhoods than White neighborhoods.25,26 In 2012, the fast food industry spent over $4 billion in advertising.27 Forty eight major food companies spent nearly $150 million alone on food marketing within schools in 2009.28 To reduce exposure to unhealthy food advertisements, the U.S. Department of Agriculture announced proposed rules in March 2014 that would only permit marketing for foods and beverages that meet the competitive foods nutrition guidelines on the school grounds during the school day.29

Specific Recommendations 

ASTHO supports infrastructure for state and territorial health agencies to address healthy eating through:

  • State health agency leadership and infrastructure that fosters engagement of multiple sectors to provide comprehensive, systemic change.
  • State health agency programs that have the ability to address healthy eating policies and programs with an effective, coordinated, sustainable infrastructure.
  • Partnerships across state, territorial, federal, and local governments, community groups, and health care systems that provide safe, culturally competent, and appropriate programs, affect policy, and implement initiatives, cross-cutting programs, and consistent targeted messages to transform communities.
  • Partnerships within state and territorial health agencies to support coordination among all programs such as nutrition and physical activity, heart disease and stroke prevention, injury and violence prevention, diabetes prevention and control, maternal and child health, the Behavioral Risk Factor Surveillance System, and other related chronic disease prevention programs.
  • Partnerships across state and territorial health agencies that support healthy eating in cooperation with agencies overseeing education, agriculture, healthcare, and other sectors.
  • Coordinated chronic disease programs that support infrastructure for all programs to have adequate and coordinated leadership that supports communications, evaluation, surveillance, and management of related programs.
  • State leadership in the adoption of healthy eating policies at the workplace within health agencies and throughout state government by implementing healthy food procurement policies that include agency food purchasing, events and meetings, vending machines, and cafeterias.
  • Preparation of laboratories, businesses and health care, and community partners to respond to outbreaks of foodborne disease.30

ASTHO supports efforts to improve the nutritional environment for infants and children through:

  • Work with hospitals, early learning centers, health care providers, worksites, government agencies, and community-based organizations to implement breastfeeding policies and programs.31
  • Breastfeeding policies that support breastfeeding in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Title V Maternal and Child Health Services Block Grant programs; encourage and support hospitals to pass Baby-Friendly Hospital practices; and support adequate time and space for breastfeeding or expressing milk in the workplace.
  • Early childhood education policies that support access to healthy foods and beverages through the Child and Adult Food Care Program, and state child care licensing standards that include nutrition and wellness guidelines and serving meals, snacks, and beverages that meet nutrition guidelines.
  • Strengthened licensing standards for early learning centers to include nutritional requirements for foods and beverages served.
  • Education policies that support healthy students through coordinated school health programs; adequate access to healthy foods and beverages through the National School Lunch and Breakfast Program and throughout the school day that meet updated standards developed by the USDA and the DGA 2010; implementation of school wellness policies; and farm to school programs.
  • Food marketing guidelines that restrict the marketing of high energy dense foods and sugar-sweetened beverages to children under the age of 18, near schools or other places where youth gather.

ASTHO supports policy and environmental changes across the lifespan through:

Agriculture Policies

  • Agriculture policies that shift federal subsidy support from highly processed foods and beverages to less processed foods, especially fruits and vegetables, that are low in saturated and trans fats, cholesterol, sodium, and added sugars; increase access to affordable fresh fruit and vegetables through commodity programs; support healthy foods in food assistance programs; expand farmers markets and encourage the use of electronic benefit transfer at farmers markets; support fresh fruit and vegetable distribution to schools; and address the problem of food deserts.

Healthy Food in Public Places

  • Foods and beverages served or sold in government facilities and government-funded programs and institutions (e.g., schools, child care centers, prisons, juvenile correctional facilities) meet nutrition standards consistent with the DGA 2010 limiting sodium and added sugars.32
  • Nutrition labeling in cafeterias and similar establishments and vending policies provide consumers with appropriate information at point of purchase.
  • Support for state health agencies to provide the regulatory structure to enforce these mandates.

Healthy Retail

  • Grants, zoning regulations, and other incentives to attract full-service grocery stores, supermarkets, and farmers markets to underserved neighborhoods, and use zoning codes and disincentives to discourage a disproportionately high availability of unhealthy foods, especially around schools.33

Menu Labeling

  • Regulations requiring fast food and other chain restaurants to provide calorie information at the point of decision-making, and other information about saturated and trans fats, cholesterol, sodium, and sugar content of standard menu items in an easily readable format.
  • Federal funding and resources to states if they have responsibility to enforce menu labeling policies.

Restaurants/Food Industry

  • Partnerships with the restaurant industry and supporting restaurant efforts to improve nutritional quality, make smaller portion options available, and provide education and guidance about saturated and trans fats, cholesterol, sodium, and added sugars.
  • Partnerships with food and beverage companies to lower sodium and added sugar content of processed, manufactured, and restaurant food and beverages over the next decade and increase the selection of low-sodium, no-added sugar foods and beverages.
  • Warning labels on high-sodium foods or sugar-sweetened beverages on supermarket shelves or on placards.
  • Addressing inequitable unhealthy food and beverage marketing practices in underserved communities.

Worksite Wellness

  • Worksite wellness policies and accreditation programs that promote a healthy work environment, including healthy foods at meetings, events, cafeterias, and vending machines; and encourage breastfeeding or expressing milk in the workplace.
  • Comprehensive policies and programs that promote colleges and universities campus wellness.

ASTHO supports outreach and education to inform and prepare providers through:

  • The identification of opportunities to assist and advocate for financial incentives for healthcare professionals and institutions such as physicians, nurses, registered dietitian nutritionists, and other clinicians, hospitals, accountable care organizations, and insurers to offer evidence-based nutrition activity counseling (including breastfeeding), develop targeted and culturally appropriate interventions, teach people how to use nutrition information to make healthier choices, and provide leadership in community-based healthy eating efforts.
  • State provision of training, educational materials, and technical assistance to communities, worksites, and schools interested in offering healthy eating programs and policies, especially targeting health disparities and other social determinants of health.
  • Support and promote opportunities to educate the public about the sodium content of foods and the effects of excessive salt consumption.

ASTHO supports the evaluation of healthy eating efforts through:

  • Routine collection and use of public health surveillance data, including BRFSS, YRBS, e-codes, and hospital discharge data to identify jurisdictions' most pressing needs and efficiently target scarce resources.
  • Collection of community design data as communities alter environments to promote access to nutritious foods.
  • State leadership in the development of robust health information exchange with the clinical sector to improve public health and clinical services.
  • Clear benchmark goals and measurement of healthy eating according to the best attainable average level of "goodness" and the smallest feasible differences in rates among individuals and groups or "fairness."
  • Harmonization of state data collection with HHS data collection on race, ethnicity, sex, primary language and disability status as required by Section 3101 of the Public Health Services Act.
  • Tracking of consumption patterns over time to ensure that other unhealthy oils and shortenings are not substituted for trans fats.
  • Evaluation of the success of trans fat, sodium, and added sugars reduction efforts in states.

Approval History

ASTHO Position Statements relate to specific issues that are time sensitive, narrowly defined, or are a further development or interpretation of ASTHO policy. Statements are developed and reviewed by appropriate Policy Committees and approved by the ASTHO Executive Committee. Position statements are not voted on by the full ASTHO membership.

Prevention Policy Committee Review and Approval: August 2014
Executive Committee review and approval: September 2014.
This Position Statement supersedes the Menu Labeling, Trans Fat and Sodium Reduction Position Statement which expired December 2013

Policy Expires: September 2017

For further information about this position statement, please contact ASTHO Prevention Policy staff at prevention@astho.org. For ASTHO policies and additional publications related to the position statement, please visit ASTHO's Policy and Position Statements page.


References

  1. Centers for Disease Control and Prevention. Adult Obesity Facts. Available at: www.cdc.gov/obesity/data/adult.html. Updated 08-16-2013. Accessed 03-10-2014.
  2. United States Department of Agriculture. Access to Affordable and Nutritious Food: Measuring and Understanding Food Deserts and Their Consequences, United States Department of Agriculture, Economic Research Service. June 2009. Available at: www.ers.usda.gov/media/242675/ap036_1_.pdf. Accessed 03-10-2014.
  3. National Prevention Council. National Prevention Strategy. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011.
  4. IOM (Institute of Medicine). Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. Washington, DC: The National Academies Press, 2012.
  5. Gunn JP, Keenan NL, Labarthe DR. Sodium intake among adults-United States, 2005-2006. MMWR 59(24);746-749.
  6. Yoon SS, Burt V, Louis T, Carroll MD. Hypertension Among Adults in the United States, 2009-2010. Available at: www.cdc.gov/nchs/data/databriefs/db107.htm. NCHS Data Brief. October 2012;107:1-7.
  7. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans 2010. December 2010. Available at: www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf. Accessed 03-21-2014.
  8. Havas S, Roccella EJ, Lenfant C. Reducing the public health burden from elevated blood pressure levels in the United States by lowering intake of dietary sodium. Am J Public Health. Jan 2004;94(1):19-22.
  9. Center for Science in the Public Interest: "About Trans Fat." Available at: www.cspinet.org/transfat/about.html. Accessed 03-10-2014.
  10. United States Food and Drug Administration: "FDA Opens 60-day Comment Period on Measure to Further Reduce Trans Fat in Processed Foods." Available at: www.fda.gov/Food/NewsEvents/ConstituentUpdates/ucm373925.htm. Accessed 03-10-2014.
  11. National Conference of State Legislatures. "Trans Fat and Menu Labeling Legislation." Available at: www.ncsl.org/research/health/trans-fat-and-menu-labeling-legislation.aspx. Accessed 03-10-2014.
  12. Center for Science in the Public Interest. "About Trans Fat." Available at: www.cspinet.org/transfat/about.html. Accessed 03-10-2014.
  13. Yang Q, Zhang Z, Gregg E, Flanders W, Merritt R, Hu F. Added Sugar Intake and Cardiovascular Diseases Mortality Among US Adults. JAMA Internal Medicine. 2014;174(4):516-524.
  14. Johnson R, Appel L, Wylie-Rosett J, et al. Dietary Sugars Intake and Cardiovascular Health A Scientific Statement From the American Heart Association. Circulation. 2009;120(11):1011-1020.
  15. Yang Q, Zhang Z, Gregg E, Flanders W, Merritt R, Hu F. Added Sugar Intake and Cardiovascular Diseases Mortality Among US Adults. JAMA Internal Medicine. 2014;174(4):516-524.
  16. Johnson R, Appel L, Wylie-Rosett J, et al. Dietary Sugars Intake and Cardiovascular Health A Scientific Statement From the American Heart Association. Circulation. 2009;120(11):1011-1020.
  17. Reedy J, Krebs-Smith S. Dietary sources of energy, solid fats, and added sugars among children and adolescents in the United States. Journal of the American Dietetic Association. 2010;110(10):1477-1484.
  18. Center for Science in the Public Interest. Anyone's Guess: The Need for Nutrition Labeling at Fast-Food and Other Chain Restaurants. Available at: http://www.cspinet.org/restaurantreport.pdf. November 2003. Accessed 03-10-2014.
  19. Center for Science in the Public Interest. Anyone's Guess: The Need for Nutrition Labeling at Fast-Food and Other Chain Restaurants. Available at: http://www.cspinet.org/restaurantreport.pdf. November 2003. Accessed 03-10-2014.
  20. Center for Science in the Public Interest. Summary of Polls on Nutrition Labeling in Restaurants. http://www.cspinet.org/new/pdf/census_menu_board_question.pdf. Accessed 03-10-2014.
  21. FDA. Proposed Changes to the Nutrition Facts Label. Available at: http://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/LabelingNutrition/ucm385663.htm. Accessed 5-13-2014.
  22. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. Journal of the American Medical Association. 2014;311(8):806-814.
  23. Harris JL, Schwarts MB, Munsell CR, et al. Yale Rudd Center for Food Policy & Obesity. Fast Food F.A.C.T.S. 2013: Measuring Progress in Nutrition and Marketing to Children and Teens. November 2013. Available at: http://www.fastfoodmarketing.org/media/FastFoodFACTS_Report.pdf. Accessed 03-11-2014
  24. Powell L, Szczypka G, Chaloupka F, Braunschweig C. Nutritional Content of Television Food Advertisements Seen by Children and Adolescents in the United States. Pediatrics. 2007;120(3):576-583.
  25. Yancey, AK, Cole BL, et al. A cross-sectional prevalence study of ethnically targeted and general audience outdoor-related advertising. Milbank Q. 2009: 87(1):155-184, 2009.
  26. Bridging the Gap and Salud America!. Healthier Marketing and Latino Kids, Issue Brief, August 2013.
  27. Harris JL, Schwarts MB, Munsell CR, et al. Yale Rudd Center for Food Policy & Obesity. Fast Food F.A.C.T.S. 2013: Measuring Progress in Nutrition and Marketing to Children and Teens. November 2013. Available at: http://www.fastfoodmarketing.org/media/FastFoodFACTS_Report.pdf. Accessed 03-11-2014.
  28. Federal Trade Commission. A Review of Food Marketing to Children and Adolescents: Follow Up Report. December 2012. Available at: http://www.ftc.gov/reports/review-food-marketing-children-adolescents-follow-report. Accessed 03-11-2014.
  29. U.S. Department of Agriculture. Local School Wellness Policy. Available at: http://www.fns.usda.gov/school-meals/local-school-wellness-policy. Updated 03-03-2014. Accessed 03-11-2014.
  30. Adapted from: National Prevention Council. National Prevention Strategy. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011.
  31. Ibid.
  32. Ibid.
  33. Ibid.