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Government Initiatives on Food and Health The federal government, as a major sponsor of research in health and agriculture, was represented at the meeting by a number of speakers and discussants. John H. Marburger III, President Bush's science adviser and Director of the White House Office of Science and Technology Policy (OSTP), delivered the keynote address "Meeting the Nation's Food and Health Challenges," to open the workshop. Joseph J. Jen, Under Secretary for Research, Education, and Economics at the U.S. Department of Agriculture (USDA) shared his thoughts on "The Changing Landscape of the Food and Fiber System: Responses to the Public Health Challenges" during the luncheon address. Van S. Hubbard, Director of the National Institutes of Health (NIH) Division of Nutrition Research Coordination, launched the discussion session with "Incentives for Multidisciplinary Science." Tommy G. Thompson, Secretary of Health and Human Services (HHS), which includes NIH and the Food and Drug Administration (FDA), marked the closing of the workshop with remarks on "Science to Improve Public Health and the Food System: Bridging the Divide." GOVERNMENT PROGRAMS AND THE HUNGER-OBESITY EQUATION Marburger, Jen, and Hubbard touched on a wide array of issues related to food 11

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12 EXPLORING A VISION and health, focusing primarily on hunger and obesity. They discussed programs to tackle food-related health problems, at times challenging participants to help devise solutions, and responded to questions and suggestions from participants, including proposed changes in government policy and practice that could facilitate nutrition-related research and education. Addressing Hunger through Technology and Education Agriculture has experienced the most dramatic productivity gains of any human endeavor in the scientific era, but Marburger reminded workshop participants that food and health issues needed to be grounded in a social context. "The most important food and health issue is providing enough food for people to satisfy their basic nutritional needs," he told the gathering. Physical and mental well- being depends first and foremost on getting enough to eat. The problem is not lack of food the existing food-production system is sufficient to satisfy basic hunger throughout the world. Instead, hunger is an economic problem. In the United States, the wealthiest nation in the world, at the height of the boom economy in 1998, 3.7 per cent of U.S. households were hungry at some time during the year. Those who went hungry did so not because of a shortage of food, but because they did not have enough money to buy it, he said. The problem is much more acute in developing countries, where more than 800 million are undernourished.~7 Marburger made the case that science, technology, and education have roles in solving the problems of hunger and malnutrition but cannot eliminate them entirely. In principle, existing technology may make it possible to meet the nutritional needs of a growing world population, but social and economic barriers sometimes stand in the way of acceptance. Until those barriers are eliminated, Marburger thought food-health issues, such as nutrition, foodborne disease, and genetically modified foods, should be viewed as secondary to hunger. Some of the obstacles are rooted in history and culture: Traditional patterns of land use, water-management issues, and cultural attitudes toward agricultural technology can inhibit the application of productivity-enhancing practices in regions that have growing populations, he said. Science and technology provide important tools for fighting hunger and malnutrition, and the United States is a leader in scientific and technologic |6 Economic Research Service (ERS). 2000. Prevalence of Hunger Declines in Rural Households. Rural Conditions and Trends. 11(2):80-86. Available on-line at ~ [January 2004]. |7 Food and Agriculture Organization of the United Nations (FAG). 2000. The State of Food Insecurity in the World: Undernourishment around the world. Available on-line at =~L~ [January 2004].

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GOVERNMENT INITIATIVES ON FOOD AND HEALTH 13 innovation, but there is a risk that research will be irrelevant because it will not be acceptable, Marburger said. Bridging the gap between availability and application is crucial, he added. He stressed the importance of education to overcome resistance to new technologies. He cited, for example, international concerns about genetically modified foods, which he said are not well understood or accepted in Europe and other parts of the world. Marburger's comments prompted audience members to point out that hunger and obesity can coexist, that hunger for calories is distinct from hunger for specific nutrients, and to question whether the support structure is in place to alleviate the latter. There may be enough food for people around the world to eat if one equates eating with energy consumption, but there may not enough to meet other nutritional needs, such as for vitamins and minerals, and the current agricultural structure may not be able to support those needs on a global basis. "The issue of overabundance of food creating health problems is an example of the mismatch between technical application and cultural practice," Marburger agreed. Epidemic of Obesity Americans are eating too much and exercising too little, and these behaviors are creating the serious health problems of overweight and obesity, USDA's Jen said. Food in the United States is abundant and affordable, incomes are at record levels, nutrition and health knowledge is at an all-time high, and yet many Americans are not eating a proper diet. Poor eating habits and many other factors have resulted in a health crisis unlike any in history. This crisis, Jen continued, does not center on a particular disease but is the product of our behavior and our freedom of choice. By eating too much and exercising too little, we are creating a serious public health problem-overweight and obesity. There is concern that the growing prevalence of obesity and its occurrence at earlier ages will increase the onset of chronic diseases and diabetes. Jen presented data on the increasing trend in overweight and obesity in the United States (see Figure 2-1 for obesity trends). He noted that more than 60

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GOVERNMENT INITIATIVES ON FOOD AND HEALTH 15 per cent of the U.S. population is overweight, and 30 per cent of those who are overweight are obese. Over 15 per cent of American children are overweight or obese, Jen added, a problem that costs almost $120 billion per year. Those numbers have doubled in the last 20 years. This trend will have severe social implications and individual costs in terms of poor health over a lengthening lifespan. The growing prevalence of obesity and its occurrence at an earlier age are likely to increase the onset of chronic disease, such as diabetes. Moreover, the rest of the world is following our pattern as standards of living increase and the cost of food declines globally. Jen noted that a host of factors influence food demand and food consumption behaviors: the types and prices of foods available, technologic advances, time pressures, attitudes and knowledge about health and diets, demographics convenience and fast foods, and changed family and social structures. Although genetic factors play an important role in obesity, it is likely that the growth in prevalence of overweight is also driven by such factors as the physical environment and human behavior. Consumer lifestyle and choice play a large role, Jen said, but many factors are outside consumer control. These include government policies on agriculture, taxes, and exports/imports; issues related to food palatability and availability; and consumer income and education. Multidisciplinary teams made up of professionals in nutrition, economics, public health, physical education, behavioral science, food technology, marketing, medical science, political science, and other fields are the key to defining and refining the underlying research that is necessary to address the problem of obesity. Jen noted that USDA, with food stamps and school lunch programs and links to the Land-Grant Institutions and other higher education entities, has an essential coordinating role for the many-faceted disciplinary teams needed to effectively handle the research, education, and outreach programs to solve the obesity problem. Ultimately, overweight and obesity are caused by an imbalance between energy intake and output, Jen observed. Average daily caloric availability in the food supply grew by over 230 calories per person in the last 10 years. Consuming 200 extra calories per day increases body weight by 20 pounds in a year. Burning 200 extra calories would require at least an extra 30 minutes of walking per day. Therefore, one may conclude that excessive intake of calories is the major problem. For most people, exercise alone will simply not solve the problem. Unless exercise is coupled with reduced caloric consumption, the obesity problem will go on unabated. A concentrated research effort will be needed to develop new approaches, tools,

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16 EXPLORING A VISION and technologies to motivate consumers into healthier eating patterns, Jen said. He pointed out that following a healthy diet requires confronting four tradeoffs taste, cost, convenience, and long-term versus short-term benefit. Approaches might include creating foods that taste good but are low in sugar and fats, and conducting research into why people choose fatty diets over low- cost, healthy alternatives, he said (see Figure 2-2 and Boxes 2-1 and 2-2~. Another possible approach might be the establishment of a nutrition-information research center that could provide resources to conduct research for use by programs, states, and local agencies. Asked to elaborate on how such a center would be structured, Jen said that it could be a one-stop resource, but admitted that he did not have specifics. Asked about USDA efforts to refocus existing programs such as school lunches, food stamps, and the extension service toward the war on obesity, Jen said that the department has laid some groundwork for building a team approach toward all these issues across USDA agencies and is trying to improve interagency efforts. .... ...... .. .... _ . ~ ................................ d ~. .. . ~ ..... , . . . ~ ~ , .. . ~. ... . ~ ~ . . . . ~. hn ~ .... .. . ~. . ~. - . ~ ~ - a d . ~ ~d . d . . lo. Ad. . d . ~ g,4 ~ ......................... . . . ..... ..... . . . . . . be. . . . . . . . . . . . . . . . . . . ~ ........... ............ ........... . ... . . ~. I ................................... .. . . . . . .. ...... . .. . . ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ..... ................................... .. ... . ale . ~. .... . .... . . . . . ...... ~ . . . ~ ~ .. ....... ........... ...... . ............................ ... ......... ... ...... . ~ . ........... .......... ........... . ................. .. . . . .. . . . ..... ... . ~ . . 20 Young, E. and L. S. Kantor. 1999. Moving Toward the Food Guide Pyramid: Implications for U.S.Agriculture. AgriculturalEconomic Report. 779:36 pp. Available at _ ~~ [October 2003].

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GOVERNMENT INITIATIVES ON FOOD AND HEALTH 17 Be ~ ............... .............. . . ~ _ ..... . ~ ..................................... . ~. - ....... . .. _ . . _ ~ ...... in .... .................... ..... .... . ~ ....... ....... ....... .. . .... . . ~. . .... ..... in .... . ~ . .. . ..... . ..... . . . .... .. . ..... .. .. . ...................................... ........ . .. ...... M ~ . ~ ~. ............................ . ~ . ~ . ~. = . . a ..... ... .......... . ~ ~ succor d ............... .. ..... ..... . ~. .... . . ...... .... . . . ... . ~. ...................... .... . _. a ............ ... ................... . ~ ................. ... ... .... ... .... .. .... . ......................... .... .... - ~ .... ... ... .... . .... . .... ................... .. ... .. . . ... . ... ... .. ..... .... ......... . ..... . . . . . ...... ..... . ..... . ...... . . . . .. . ..... . . ..... .. .......... . . ..... . . . ....... . .... ... .......................... .. . ... . . ... . .............. ... ... .... ... ~ ... . ......... ... .... ... ~ . ... ... .... Airs ~ ~ d ~ _ ..... a ........ .... . a. ..... .... .......................... ....... . . . . a ...... ~ . . . . . . . ~. . . . .... a ''' s . ~ _ _ ..... ........... . ~ .... ................ .... .... . .... .... ... ................... . ... ~ ~ ..... . . ~ .... ...... ............... ....... . .... . ... ... .... . ... ... . ~ ............. 0 ..................................... .............. . .... ..... ........ ~ .. .. .. .. .. .. .. ... ... . ~ ~ . ..... ..... . ..... . ..... ..... ..... ..................... ... . .. .. .. . .. .. .. at.. ..........~..... .......... w .... .... ... .... .... .... .... .... ............... ... .... ... ... .... ... ..... hi............ .... .... ........ ... . ... .. ... .. .. .... ........................................ ..........................._

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18 EXPLORING A VISION Obesity Rampant Among Minorities Obesity and overweight is a significant problem in all populations in the United States, and worldwide, Hubbard noted, providing additional statistics on obesity. The problem is especially evident among minority women, he said, noting that one out of every two black women is considered obese. Nearly 40 per cent of Mexican American women also are obese, compared with about 30 per cent of non-Hispanic white women and 33 per cent of women overall. INTEGRATED RESEARCH AND COLLABORATION The White House Office of Science and Technology Policy was conceived to foster interagency, and therefore interdisciplinary, cooperation. No other country distributes its scientific responsibilities over so many agencies, some of them quite large, and no other country relies so heavily on its universities to provide basic research, information, and work to address problems of social importance, Marburger said. It is a complex system, but it has proved robust and effective. The federal investment in food-related research is not officially tracked, but includes most of the USDA's programs, totaling about $2 billion, and relevant programs in agencies including NIH, the National Science Foundation (NSF), the National Aeronautics and Space Administration (NASA), the Environmental Protection Agency (EPA), and the Departments of Energy, the Interior, Commerce, and Defense, which total about $0.5 billion. The total federal investment is about $2.5 billion per year in food-related research and development. OSTP's National Science and Technology Council (NSTC), which consists of the Cabinet-level Secretaries of the agencies that have science in their portfolios, oversees interagency working groups on specific topics to enhance coordination and cooperation, and to advise the Office of Management and Budget (OMB) and the President as he prepares his budget request to Congress. A number of NSTC standing committees address food-related issues: the committee on

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20 EXPLORING A VISION science, the committee on environment and natural resources, and the committee on technology, as well as the committee on homeland and national security, because the extensive infrastructure of the food production and delivery system could be disrupted by terrorist interventions. There are interagency efforts related to food and health issues on plant, animal, and microbial genomics; such food safety issues as dioxin and mercury in the environment; aquaculture; climate change; agricultural biotechnology and water management; and education and workforce issues. Marburger noted that activities like this workshop on food and health helped to identify gaps in programs and important research that should be addressed. He emphasized the timeliness of the workshop, noting that it was taking place at a time of unprecedented rapid change, in attitudes, in the technology of food production, and in our understanding of health. The vulnerability of the food supply clearly is increasingly visible; catastrophic outbreaks of mad cow disease, foot and mouth disease, and other agricultural pests and viruses seem to be emerging more rapidly today as a result of increasing globalization. Marburger cited the recent monkey pox and Severe Acute Respiratory Syndrome (SARS) epidemics. He also called on the plant, animal, human biology, and medical research communities to emulate the balance that scientists working on the interrelated functions of genes, cells, and metabolism had established. In an effort to address this, OSTP, with OMB, has proposed and issued guidance that research on the molecular basis of life processes receive national priority. The time is ripe for an integrated approach to nutrition, health, and disease prevention, Hubbard said, noting that the current political climate is favorable for providing incentives for multidisciplinary research and collaboration. Hubbard attributes this new climate to two key events: the release in March 2003 of a World Health Organization report on diet, nutrition, and the prevention of chronic disease; and the launching in June 2002 of President Bush's HealthierUS initiative, which emphasizes the importance of physical activity and nutrition in promoting good health and preventing disease. As a result of this initiative, HHS is shifting to a prevention mode, he said. The department is looking at the health-care system to see what can be done to improve it and to reduce health-care costs. The department's Public Health Service is also sponsoring a series of regional workshops that bring together federal, state, and local representatives of various programs in HHS, USDA, and state health departments to discuss what they are doing about obesity and other health problems. Hubbard stressed the need for multidisciplinary research and the importance of partnerships in achieving HHS's public-health goals. It is imperative that federal agencies and other organizations work together to make the most of

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GOVERNMENT INITIATIVES ON FOOD AND HEALTH 21 available resources to address research needs, he said. One way is to ensure that new research proposals add value to efforts already under way rather than duplicate them. Hubbard challenged university representatives to identify "glue investigators" in their institutions who could be liaisons on cross-disciplinary projects funded by "glue grants." "Many of the principal investigators may not have the time to interact with all the other investigators in the multidisciplinary teams," he said. "But there are usually some key people who will provide the glue to hold the different projects together. Perhaps there should be some special means of supporting that type of individual." HHS FOOD- AND HEALTH-RELATED ACTIVITIES The Department of Health and Human Services (HHS) has an annual budget of $525 billion the largest of any federal department and includes such agencies as the Centers for Disease Control and Prevention (CDC), NIH, and FDA, which all have important roles in improving integration in the food and health systems. Secretary Thompson, in his closing remarks, reinforced the government's concern about food-related diseases that are costing lives and dollars, including diabetes, which affects 18.2 million people (and another 16 million who are prediabetic) and costs $132 billion annually, and obesity, which kills 300,000 and costs $ 117 billion annually. He noted that diabetes is a problem in minority communities such as Native Americans, Hispanics, and African Americans, and that there has to be more public outreach about it. The U.S. agricultural sector could do more to promote good nutrition and health, Thompson said in response to a question about what agriculture might do differently to benefit public health. Despite clear guidelines for a healthy diet, lessons about good eating behavior are not reaching schools, minority communities, and hospitals and clinics, and the food and health community needs to get the message out. He added that the National Academies through activities such as their workshops can be helpful in those efforts. Recognizing that leaders often have to lead by example, Thompson reported that he has taken a personal interest in tackling food and health problems, increasing his physical activity while wearing a pedometer and losing 15 pounds. Thompson described some of the many health-related concerns and challenges that have come before HHS in the past few years, as well as some of its victories (see Box 2-3 for an example). Due in part to the response to increased security risks, HHS has doubled the number of its food inspectors from 750 to 1,500. As a result, about four per cent of food imports are being inspected, up from 0.5 per

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22 EXPLORING A VISION cent three years ago. Food inspectors also are using new technologies in that effort. HHS launched a Healthy Cities campaign in September 2003 with initial funding of $15 million, he said. To encourage healthier behavior, a community or city can develop programs to reduce chronic disease and risk factors such as diabetes, obesity, asthma, and tobacco smoking, and submit them to HHS to receive funding and be declared a healthy city. HHS will seek increased funding for the campaign, to total $125 million, for next year, he said. Looking to the future, President Bush will unveil a new food initiative shortly, Secretary Thompson told the gathering. He said the initiative would be coordinated by HHS, as well as USDA and the Department of Homeland Security, but otherwise declined to give any details, saying President Bush would be making an announcement later. ......................................................... .......... . .. 23.~ In ~~ ~ Ore ~ Hi . ~ ~ _ ................................... ........... . ~ ~ ~ ~ . ~ . . ..... . .... .... ...... .. .... . . .......................... ......... .... _ ......... . ~. ....... ........ ............. ............ . .... som ~ . ~ . ~ ........... .... heath Ed . ~ ~ ..~. . . . ~ ~ . . . .. .... ... . ~ ..~ ..... . .... .... . . . . . . . ~ . .................... . ~ . ~ . ~ - . .... . ...... . . ..................... . . . . . . . ... . . . . . . . ~ .................................. ..... .... 23 HealthierUS. 2003. Available at _~ [October 2003]. 24 Healthier US. 2003. Available at www he~ie~ [October 2003].