World Health Organisation (WHO)’s Global Status Report on NCDs for 2014 terms the problem as “one of the biggest health and development challenges of the 21st century, in terms of both the human suffering they cause and the harm they inflict on the socioeconomic fabric of countries, particularly low- and middle-income countries”.
Non-Communicable Diseases (NCDs) are the biggest global killers and the leading cause of preventable morbidity and disability, affecting more people each year than all other causes combined. They account for more than 71% of annual estimated deaths globally, 80% of which occur in developing countries, and NCDs are forecast to drain over US$50 trillion from the global economy over the next 10 years. The 15 million deaths caused by NCDs each year are premature deaths (before reaching the age of 70). According to former DG WHO, Dr Margaret Chan, there is unequivocal evidence to demonstrate that noncommunicable diseases are largely preventable.
Recognising the devastating social, economic and public health impact of NCDs, in September 2011, world leaders adopted a political declaration containing strong commitments to address the global burden of NCDs and gave several assignments to the World Health Organisation (WHO) to help support country efforts. One of them was the development of the WHO Global action plan for prevention and control of noncommunicable diseases 2013–2020. Commonly known as the Global NCD Action Plan, it includes nine voluntary global targets and a global monitoring framework. The Global NCD Action Plan and the voluntary global targets were adopted by the World Health Assembly in 2013. On that occasion, the then DG WHO, Dr Margaret Chan, warned that delay in taking action [on NCDs] will result in worsening of the NCD burden and an increase in health care costs.
It is quite ironic that a highly communicable disease (such as the Covid-19) was destined to add tremendous impetus to the existing global health discussions on dealing with their Non-Communicable kin and emphasise action in an unprecedented manner. This is due to the emerging statistical evidence that people living with NCDs constitute a risk group that is far more vulnerable to developing serious illnesses or even death from the Covid-19 infection.
The human, social and economic consequences of NCDs are felt by all countries but are particularly devastating in poor and vulnerable populations. Almost three quarters of all NCD deaths and most premature deaths (82%), occur in low- and middle-income countries like Pakistan.
Recent economic development, prosperity and urbanisation have together contributed towards a notable shift in food and dietary patterns. Pakistani society has gradually moved towards consuming unhealthy diets. This is evident by an increasingly low consumption of fruits and vegetables in Pakistan amidst a high consumption of salt, sugar and unhealthy processed food products. There is also the significantly contributing factor of industrially produced trans fatty acids (iTFAs) in this equation. The iTFAs are a harmful fat found in vanaspati ghee, margarines and bakery shortenings. Research has emerged suggesting a high correlation between high intake of iTFAs and Cardiovascular diseases (CVDs).They are known to increase levels of dangerous LDL cholesterol and decrease the levels of healthy HDL cholesterol in the blood.
A significant number of NCD deaths can be prevented by limiting iTFA intake at population level and that is why it is regarded as one of the most cost-effective and straight forward interventions for reducing NCD death and simultaneously reducing the economic burden of NCDs on health systems and their capacity to deliver. Evidenced by a recent European Union study, it is interesting to note that that (in EU countries), 97 per cent of CVD funding is for treatment. Clearly, the centuries old saying “prevention is better than cure” is being neglected here. Reduction in NCD-related death and economic loss can be achieved by aligning national food supply on WHO recommended policy actions for iTFA elimination.
WHO recommends two policy actions. a) Mandatory maximum limit of 2% iTFA in all foods
b) Ban on partially hydrogenated oils (PHOs)
Many countries around the world have achieved, with varying degrees of success, reductions in iTFA intake at population level. Many high-income countries like Denmark and Canada have demonstrated remarkable progress. Certain middle- and low-income countries like Iran, India and Argentina too have made good progress in reducing iTFA intakes. Closely examining their models and drawing upon their experiences, it is possible to set out a roadmap for such a change in Pakistan. The case study of Denmark is of particular importance since it achieved the highest reduction in iTFA intake in a very short period. Such remarkable progress was achieved through a combination of:
a) research into identifying dietary sources of iTFA in national diet documenting iTFA consumption among different segments of the population
b) public awareness campaigns via print and electronic media to highlight the health hazards of increased iTFA intake
c) Mandatory labelling of iTFA content in packaged foods.
d) Later the introduction of a mandatory limit of 2% iTFA in all foods
e) Strong political stewardship exhibited in the form of a high-powered Danish Nutrition Council (DNC) to steer the entire effort.
f) Concrete monitoring framework to ensure compliance to the new regulations by food producers and importers
Other success stories of iTFA reduction upon close examination reveal a set of common features i.e. mandatory labelling of packaged food and mandatory limits on iTFA content in foods via regulations, data gathering and research by academia and health ministries on iTFA consumption in various segments of the population, research on replacement oils by the industry, strong public awareness campaigns, strong political stewardship by the respective political governments and robust monitoring mechanisms via empowered monitoring bodies.
Prevention approaches enabled through multi-sectoral public policies, and legislative and regulatory measures that enable affordable, healthy lives and environments are far more cost-effective than the tertiary healthcare NCD model. However, adoption and financing of prevention is severely hindered by absence of knowledge related to the modalities of adoption, financing, and implementation of such approaches. The World Health Organisation developed a REPLACE framework (Review, Promote, Legislate, Assess, Create, Enforce) to serve as a roadmap for countries to reduce and eliminate iTFAs.
Given the NCD and particularly the CVD burden in Pakistan, the country must develop a comprehensive response to the iTFA challenge. This response needs to be multi-sectoral, based on research and evidence, and set out a course of action that can lead to iTFA reduction and eventual elimination from the food value chain of Pakistan. Efforts are already underway by the Government of Pakistan via the Nutrition Wing of Ministry of National Health Services Regulation & Coordination (MoNHSR&C) for creating an enabling environment for iTFA reduction in collaboration with WHO and other leading health research institutes in the country. To this end, a broad-based multi-sectoral National TFA Technical Advisory and Advocacy Group was established in September 2019. The advisory group has a good balance of federal and provincial government officials from health ministries and food authorities, consumer protection groups and technical experts from the industry as well as allied international organisations. This advisory group is supposed to provide strategic direction to the TFA elimination efforts in Pakistan to act as a coordination and information sharing platform to support development of related policy documents/protocols and harmonisation of regulation and enforcement modalities.
A recent Council of Common Interests (CCI) decision ruled that only Pakistan Standards and Quality Control Authority (PSQCA) could regulate business of food standards and certifications in the country. This provides the government with a unique opportunity to redefine standards related to iTFA content in foods and oils through the federal body of PSQCA in the short term and the relevant legislation (which always takes considerable time) can follow suit. It is important to note that the industry almost always requires a grace period to switch to new equipment and build capacity to comply to new standards. This is also in conjunction with the globally recommended best practice of giving industry a bit of grace period to adjust to new regulations/standards. New iTFA standards can be defined with the proverbial easiness of “a stroke of a pen” and shall be a good starting point for the industry to realise that when it comes to iTFA, the state means business. This is going to catalyse the industry to start gearing up for complying with the new iTFA standards. In the meantime, GoP shall be at ease with the political maneuvering of bringing about the legislation on iTFA. By the time legislative framework is in place, industry would have had their grace period making immediate enactment and enforcement of the iTFA legislation. The grace period also represents a good time window to develop iTFA-testing labs, testing capacity and personnel training.
A caution that needs to be exercised here is that there might be a tendency not to legislate and rely solely on new iTFA standards. It is important to note that legislation creates a more binding environment for the businesses compared to standards only. Evidence around the world has shown that regulations backed with credible penalties and fines work best in eliminating iTFAs. Thus, legislation is preferable since it provides the opportunity to fully define a monitoring framework, authorities/bodies tasked with monitoring, dealing with violations, penalties and standard operating protocols. Mandatory labeling of iTFA content on every packaged food again can be achieved only through legislation and not by standards control.
While all these arrangements may be expected to work reasonably well for the packaged foods segment, the open food manufacturers and fresh food producers like bakeries and street hawkers and open eateries are difficult to monitor and regulate. Compliance can only be achieved by mustering support from the primary stakeholder group in the equation, “the consumers”. In an environment where only the iTFA-free fat sources are available on the shelves, a strong consumer-side demand directed at the open/fresh foods producers for providing fresh foods prepared from iTFA free sources is the only effective way to ensure compliance from this sector which is difficult to monitor. For that customer demand to become a reality, there is a need for creating mass Consumer Rights awareness among the consumers through media and consumer emancipation programmes focusing on protecting and defining consumer rights, equipping them with the right tools to self-organise and unionise.
The end goal is achievable and the dream of having a “trans-fat free Pakistan by 2023” can turn into reality. All of this can be done in an inexpensive, durable, and sustainable way and will above all save lives.