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Policy Subsystems

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Previous Figure Next Figure. Email or Customer ID. Forgot password? Old Password. New Password. Password Changed Successfully Your password has been changed. Returning user. Request Username Can't sign in? Forgot your username? The Industrial Revolution also encouraged widespread migration towards cities, resulting in overcrowding, hunger and poor sanitation. Outbreaks of communicable diseases spread rapidly under these conditions, particularly cholera.

This became a major impetus for governments to develop legislation on sanitation and to improve living conditions in support of public health [ 49 ].

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Miasmic theory was ultimately invalidated by the germ theory of disease proposed by Pasteur, Koch and others by the end of the s [ 50 ]. Here, disease is caused by microorganisms and other contaminants in food and water [ 51 ]. Hence, food safety became a significant public health priority as a result of sanitation efforts to combat pathogenic disease. Nutrition science extended to the development of food processing techniques and methods like pasteurisation to reduce the risk of food-borne illness [ 27 ].

Early food policies sought to protect public health by addressing food safety and adulteration [ 52 ]. In addition, education programs and early institutional frameworks for PHN emerged during this time, namely the founding of ministerial departments of health [ 20 , 53 ].

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The incidence of food-borne illnesses declined dramatically as a result of these measures, alongside increasing recognition of the wider benefits of public—private collaboration and the responsibilities of governments and their agencies to improve food safety [ 27 , 49 ]. These early developments allowed PHN to transition to a new era and the emergence of official nutrition guidance. According to Kuhn, in the transition from Phase 1 to 2, a dominant paradigm develops as actors begin to form a consensus around conceptual frameworks, terminologies, methodologies and modes of inquiry.

Anomalies that are difficult to explain under the current paradigm may occur but are usually resolved. The global malnutrition burden in the first half of the 20th century was characterised by hunger and micronutrient deficiencies particularly beriberi, scurvy and pellagra , thought to be infectious or pathogenic in nature. In , Funk isolated a substance vitamin B 3 or niacin previously shown to be essential in the diet for the prevention of beriberi.

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Funk therefore proposed that such diseases were caused by the deficiency of these essential substances in food [ 54 ]. Vitamins became the primary focus of nutrition research over the next 30 years [ 23 ].

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  • In order to meaningfully influence population health outcomes, vitamin theory needed to be endorsed by governments and industry [ 26 ]. The achievements of food and nutrition scientists during the s and s shifted the focus from whole foods to nutrients. Micronutrient deficiencies gained particular prominence after the declaration of World War I, as many young men were rejected from service for health reasons [ 20 ]. World War II posed a significant threat to food security as a result of actual and potential food shortages.

    Governments began to harness nutrition knowledge for utilitarian purposes [ 26 ]. Nutrition policies emphasised the importance of adequate population nutrition by focusing on food rations and fortification [ 20 ]. As Zeiesel et al. From the reductionist point of view, diet is reduced to food groups, food items, and food constituents and health is perceived as purely physical in nature, reduced to multiple systems, their components, and biological markers [ 58 ]. Box 1 defines NRVs, their purpose and scope. Early versions of the NRVs included just nine nutrients—protein, calcium, iron, thiamine, riboflavin, niacin, ascorbic acid, and vitamins A and D.

    As the scientific evidence base to support the quantification of individual nutrient requirements expanded, the number of recommended nutrients in NRVs increased [ 62 ]. Current editions of the NRVs include recommendations for over 30 macronutrients, vitamins, minerals and trace elements. ULs set out the highest amount of daily nutrient intake that is unlikely to cause adverse health effects among healthy populations [ 63 ].

    The promotion of dietary adequacy through the development of NRVs continues today. Nutrient reference values under development by the FAO and in the US continue to extend the traditional emphasis on dietary adequacy towards the prevention of non-communicable diseases NCDs. Kuhn postulates that in the shift from Phase 2 to 3, normal science becomes difficult when anomalies continue to accumulate over time, revealing weaknesses in the paradigm.

    If the paradigm cannot continue to explain these anomalies, a crisis period occurs.

    The application of NRVs to PHN policy and practice led to a reduction in the prevalence of micronutrient deficiencies. However, they were predicated on the idea that excess was preferable to deficiency [ 67 ]. Obesity had by that time been recognized as a diet-related condition but was not considered as serious as malnutrition resulting from dietary inadequacies [ 56 ]. After World War II, the mechanisation of farming and improved technological capabilities of the food processing industry increased the availability and variety of foods significantly [ 56 ].

    The focus of nutrition science and PHN had begun to shift towards an era of dietary excess and imbalances, an anomaly inconsistent with the dominant nutrient deficiency paradigm [ 27 , 69 ].

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    Nutrition scientists began to investigate the links between the overconsumption of various nutrients and chronic diseases from the late s and early s, establishing a number of ambitious cohort studies that followed thousands of individuals over time. The Framingham Study identified multiple risk factors for cardiovascular disease CVD , including elevated blood cholesterol and obesity [ 70 ]. Findings from the Seven Countries Study allowed Keys to establish the hypothesis that CVD risk was influenced by the composition of total fat, saturated fat and cholesterol in the diet [ 71 ].

    This established one of the most dominant and lasting assumptions in nutrition guidance—that dietary fat was a likely risk factor for CVD and that replacing saturated fats from animal sources with vegetable oils could lower blood cholesterol levels and potentially prevent heart disease [ 72 ]. Yudkin challenged the dietary fats hypothesis by suggesting that sugar consumption could be the primary agent in CVD risk [ 73 ], but was largely ignored by the nutrition science community.

    Discourses, Ideas and Anomalies in Public Policy Dynamics

    Throughout the s, a number of non-government health organisations published dietary recommendations to prevent CVD. While all groups agreed that the consumption of total fats should be reduced, there was limited consensus in recommendations on how best to achieve this goal [ 29 ]. Recommendations for other chronic diseases were developed in response to increasing evidence from nutrition science research.

    Some disease-specific dietary recommendations conflicted with those for other conditions [ 27 , 76 ]. Seeking to balance these competing risk factors, governments began developing dietary goals throughout the s, representing quantified targets for selected macro- and micronutrients to support optimal nutritional health and prevent diet-related chronic diseases, expressed as average national intakes [ 27 ]. These are further defined in Box 2.

    Dietary goals extend the quantification of individual nutrients and food components in NRVs but are a precursor to dietary guidelines, which can then be provided as a way to shift population diets towards achieving the dietary goals [ 42 ]. The Dietary Goals released by the US in recommended the reduction of dietary fat consumption by 40 percent to 30 percent of total energy intake and of refined sugar from 45 percent to 10 percent of total energy intake [ 77 ].

    However, the release of the goals generated widespread controversy among health professionals and the food industry due to the lack of consensus around the impact of certain food components on chronic disease risk, particularly among stakeholders with vested economic interests in food supply and production [ 56 , 75 ]. A broad international agenda to support the development of healthy public policy was developed during the s and s led by the WHO [ 78 , 79 ]. Dietary guidelines also appeared at this time. Norway published the first set of dietary guidelines in , followed by the US in [ 44 ].

    Dietary profiles outlining the foods and nutrients associated with wellbeing and protection against disease were quantified and presented by UN bodies, governments, their agencies and authoritative organisations as dietary guidelines for populations. Dietary guidelines continued to focus on individual nutrients and food components, particularly the overconsumption of calories, total and saturated fat, sodium and sugar, and the underconsumption of dietary fibre [ 80 ].

    By the s, nutrition scientists and policymakers began to acknowledge that people eat foods and not nutrients [ 81 ]. Here, diet and health represent complex systems involving non-linear interactions of multiple foods, in turn comprised of multiple nutrients at any one time [ 58 ]. Subsequently, revisions of the first generation of dietary guidelines became more food-based.

    Box 3 provides a further definition [ 82 ]. This indicated a significant departure from policies shaped solely by nutrient requirements, towards an agenda set by the public health concerns of the day [ 43 ]. The process resulting from this work begins with an analysis of the most critical public health issues that are related to diet within a given context, and outlines strategies to identify food-based approaches to address these issues [ 28 ].

    These efforts were further strengthened by the Second International Conference on Nutrition, held in November [ 83 ].

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    Since the consultation, some low- and middle-income countries have also commenced development of FBDGs. Many of these countries face large differences in diet- and nutrition-related health outcomes between their wealthy minorities and poor majorities. Throughout this period, hunger and malnutrition began to coexist with obesity and diet-related chronic diseases in many countries and regions.

    Nutrition transitions are associated with social changes and their influence on dietary patterns, including urbanisation, workforce changes and the globalisation of food systems [ 56 , 85 , 86 ]. Collectively, the second generation of dietary guidelines were more varied than the first due to the significant differences in individual country contexts e. In a shift from Phase 3 to 4, Kuhn posits that crises can often be resolved by normal science but that there are other times when the efforts of normal science within a paradigm will fail.

    Subsequently, the discipline enters a new phase where underlying assumptions of a discipline are re-examined, and a new paradigm is established.