本文是留学生assignment范例，题目是“Health Policies on Sodium Levels in Processed Foods（关于加工食品中钠含量的健康政策）”，在省一级推行公共卫生营养政策(特别是减少钠摄入量)可能很困难，因为涉及的健康保护立法和公共卫生系统已经进行了一些改变(16)。发起诸如营养政策等大型体制改革，需要考虑到所涉及的个人的广泛范围和所需的多种经济资源。此外，诸如减少钠含量、食品标签或强化牛奶等改变需要大量的努力和长时间来引入、建立和维持。因此，需要研究来证明钠应该减少，例如，加工食品。这类研究涉及大量资源(人员、资金等)，可能非常耗时，通常需要数年时间。
Abstract 摘要
It can be difficult to introduce public health nutrition policies (specifically sodium reduction) at the provincial level, as several changes are introduced to the health protection legislation and public health systems involved (16). Initiating large institutional changes such as nutrition policies, requires consideration of the extensive range of individuals involved, and multiple economic resources required. Also, changes such as sodium reduction, food labelling, or fortification of milk require extensive effort and long periods of time to introduce, establish and maintain. As a result, research is needed to prove that sodium should be reduced in, for example, processed food. Such research involves significant resources (people, money, etc.), and can be very time consuming, often requiring several years.
Nutrition-related changes (such as sodium reduction) proposed by healthcare professionals are difficult for policymakers to implement due to various and clashing factors involved. This requires difficult adaptation by consumers and various modifications by the food industry (10,12). Making such changes is challenging for the food industry, as their food products have a specific nutrient composition (eg. sodium) and modifications to the composition changes the taste and texture of food products. As a result, it is difficult for food industries to determine what addition or removal of ingredient (s) is/are necessary to maintain the satisfaction of consumers. In addition, reducing salt would decrease the product shelf life and affect the safety of the product.
由于涉及各种相互冲突的因素，卫生保健专业人员提出的与营养相关的改变(如减少钠)对于决策者来说很难实施。这需要消费者的艰难适应和食品工业的各种修改(10,12)。做出这样的改变对食品行业来说是一个挑战，因为他们的食品产品有特定的营养成分(如。钠)和对成分的修改会改变食物的味道和质地。因此，食品行业很难确定添加或删除哪些成分是/是必要的，以保持消费者的满意度。此外，减盐会降低产品的保质期，影响产品的安全性。
1.Institutions, Interests, Ideas机构、利益、想法
Both levels of government have imperative involvement in food and nutrition policies. A large focus is placed on the federal government to approve changes to current regulations (eg. trans fat banning) and standards focusing on nutrient content (eg. sodium reduction), food fortification, nutrition labelling and health claims (11, 19). Provincial governments play a proactive and supportive role in dietary guidance implementation. In addition, both levels of government require collaboration with many stakeholders from health professionals, academics, non-governmental organizations and others to promote changes including re-formulating products (eg. lower sodium).
这两级政府都必须参与粮食和营养政策。联邦政府在批准对现行法规(例如，法律法规)的修改方面受到了很大的关注。反式脂肪的禁止)和关注营养成分的标准(如减少钠)，食品强化，营养标签和健康声明(11,19)。省级政府在膳食指导实施中发挥积极和支持作用。此外，这两级政府都需要与卫生专业人员、学者、非政府组织和其他许多利益攸关方合作，以促进变革，包括重新制定产品(例如。钠)。
In terms of sodium reduction in processed foods, the federal government has not approved regulations pertaining to sodium reduction policy (13). However, within the federal level, Health Canada is an important regulatory group advocating for sodium reduction. Health Canada is an intermediate between the government and general public that provides Canadians with resources and tools to improve and well-being. In addition, Health Canada is accountable, under the Food and Drugs Act (FDA), for the development of standards, regulations and policies associated to foods sold in Canada, to ensure acceptable nutritional quality and food safety standards are followed. Accordingly, one of their key functions is ensuring Canadians are safe by regulating and monitoring food, health and consumer products (4,8,11). *
The legislative framework that closely relates to sodium reduction strategies involves regulation provisions that fall under production, marketing and sale of foods in Canada. The leading act involved in sodium reduction is the Food and Drug Act in the Department of Health, whose key function is ensuring Canadians are protected from health hazards and false claims in the sale of foods. Sections B.01.502 and B.01.513 of the Food and Drug Regulations (FDR) focuses on the acceptable nutrition content claims that can be articulated or inferred (based on composition of nutrients) and their conditions. Furthermore, section B.01.601[1] of the FDA states when disease risk reduction claims are permissible with respect to sodium, when food products have low composition, which is the goal of sodium reduction strategies (4, 10). *
Requests made by Health Canada are addressed and approved by Minister of Health and Long-Term Care based on certain criteria. Approval is dependent upon adequate evidence that the change will be greatly favorable to the health of Canadians. Furthermore, the office of Health Promotion federal efforts endorse sustenance of good health based on the recommendations of Health Eating Strategy (6,14). As a result, they play an important role in dietary guidance, promotion & knowledge translation, surveillance, research & data analysis and policy leadership & collaboration (2, 11). *
The College of Dietitians of Ontario is a regulatory body within the federal government that helps to ensure the dietetic regulatory framework reflects the current dietetic practice. Dietitians of Canada (DC) is an important group in this policy area working with various regulatory bodies and advocacy groups, a member of the Sodium Working Group, and monitors activities in Health Canada’s Eating Strategy. Furthermore, DC promotes the need for a national database where monitoring and surveillance can improve the understanding of gaps in the food supply and evaluate the nutritional intake of Canadians (7).
In addition to governing bodies, many in-field organizations and advocacy groups, who overlap, play a role in this policy area. For example, some groups include Nutrition Facts Education Campaign, Eat-Well and Food-Epi Research Committee. Blood Pressure Canada (now Hypertension Canada) and the Heart and Stroke Foundation are two leaders among non-governmental groups that inform Canadians about the implications of high sodium intake (3, 19, 21).
2.Existing Provincial Regulations现有省级法规
Currently, there are no existing provincial regulations for sodium reduction in Ontario.Based on the evaluation results of the Sodium Working Group, provinces were promoting greater investments in sodium reduction research by all involved parties (18). Provinces and members of the Sodium Working Group have advocated for sodium reduction through research committees, monitoring/evaluation of current programs, and through public awareness and education. However, in the report received in January 2017 (stating progress made), the food industry was not successful in their approach of sodium reduction (13,18). Both federal and provincial Ministers of Health have emphasized sodium reduction as a nutrition priority and recommended a target RDA of 2300mg/d by 2016. This has yet to be approved with the expected year now moved to 2020.
目前，安大略省还没有减少钠的省级法规。根据钠工作组的评价结果，各省正在促进所有有关各方加大对减少钠研究的投资(18)。各省和钠工作组成员通过研究委员会、监测/评估当前项目以及通过公众意识和教育倡导减少钠。然而，在2017年1月收到的报告(说明进展)中，食品行业在减少钠的方法上并不成功(13,18)。联邦和省级卫生部长都强调减少钠摄入量是一项优先营养事项，并建议到2016年将RDA目标定在每天2300mg。这一计划尚未获得批准，预计的年份现在已移至2020年。
Due to this unsuccessful approach to sodium reduction, monitoring and surveillance undertakings are imperative in determining the best practices for sodium reduction (13,18).
3.Existing Programs现有的项目
There are many existing programs that affect nutrition policies in Ontario; two key ones are provided by Dietitians of Canada (DC) and Hypertension Canada. The programs provided by these two institutions are vital in sodium reduction as they both provide educational programs and resources for all Canadians. DC provides both preventative and treatment-focused education programs that tackle sodium reduction strategies for all age groups. It provides online resources including “sodium sense” fact sheets for all ages, offering guidance in order to make informed and healthier selections. DC is essential in contributing to improved nutritional intake and well-being through their continuous advocacy and efforts towards sodium reduction (7). In addition, locally, Toronto Public Health provides programs that educate Toronto residents towards reducing salt in their diets (20).
在安大略省，有许多现有的项目影响着营养政策;两个关键的是由加拿大的营养师(DC)和加拿大高血压提供的。这两家机构提供的项目对减少钠至关重要，因为它们都为所有加拿大人提供教育项目和资源。DC提供以预防和治疗为重点的教育项目，解决所有年龄组的减少钠战略。该网站提供在线资源，包括针对所有年龄段的“钠感”事实说明，提供指导，以便做出知情和健康的选择。DC通过持续倡导和努力减少钠摄入量，对改善营养摄入和福祉至关重要(7)。此外，在当地，多伦多公共卫生提供了教育多伦多居民减少饮食中盐的项目(20)。
Hypertension Canada provides educational programs online and within communities to establish effective strategies to address high sodium intake. This program provides guidance for both healthcare professionals and the general public concerning (but not limited to) sodium reduction. Some tools provided by Hypertension Canada include: what meals should consist of, resources available to monitor daily intake how to read nutrition labels to avoid high sodium, and what to include/exclude in your meals (1, 21).
4.Policy Changes政策变化
There are no policies set in place for sodium reduction in Ontario. In the past, major steps have been taken towards the development of one, but none have been successful. Ontario’s Bill C-460 on sodium reduction was one bill under consideration, but rejected by the Federal Government in 2013. This health public policy set voluntary targets to reduce sodium levels for food manufactures. If reducing the composition of sodium was not possible, the food manufactures needed to clearly state and warn consumers that the food product was high in sodium. This bill was intended to allow Canadians to make health-conscious choices as information of sodium levels on food products was straightforward.
安大略省没有制定减少钠的政策。在过去，已经采取了重大步骤来发展一个，但没有一个是成功的。安大略省关于减少钠的C-460法案是正在考虑的法案之一，但在2013年被联邦政府否决。这一卫生公共政策为食品制造商制定了减少钠含量的自愿目标。如果降低钠的成分是不可能的，食品制造商需要明确说明并警告消费者，该食品的钠含量很高。这项法案的目的是让加拿大人做出有健康意识的选择，因为食品中钠含量的信息是直截了当的。
Many benefits could have resulted from implementation of this policy. With Bill C-460, reduction and regulation of sodium composition in food products would have undoubtedly helped to combat elevated cases of chronic diseases/conditions such as high blood pressure and stroke. According to research, Bill C-460, long term wise would have reduced DAYLS, reduced premature death and enhanced the efficiency of Canada’s economy, saving billions in healthcare costs (5, 10, 14).
However, one challenge encountered was sodium reduction in processed foods by food companies is still in progress (even in 2018), as majority of the food industry has reduced sodium levels to required values stated by Health Canada. Very minimal or no changes have been made by food manufactures in a goal that was supposed to be achieved at the end of 2016. One main challenge is the reformulations in the composition of salt, which usually plays a technical or safety role in food, has indefinitely made it difficult for manufacture. For example, salt is essential in its influence on the texture and flavour of aged cheese, or simple flavour profiles like tomato juice that only contain three ingredients (salt being one of them) would be difficult to alter and recreate (10, 12,13). In addition, consumers’ acceptance is another key problem, as can be noted by Campbell’s reduction of sodium in their soups, which resulted in significant sale slumps (15). Subsequently, Campbell’s company discarded their sodium reduction efforts, providing limited options with low sodium soups, and returning sodium composition to their previous formulations (15). Furthermore, food industries need to consider cost and resources to make drastic changes to processed foods (12, 13, 14).
Health Canada has introduced to the public mandatory front-of-package labelling of nutrition symbols for foods high in sodium, sugar and saturated fat. Health Canada has stated a label will be required in food products that have more than 15 per cent of the daily recommended intake. This mandatory front of package labelling for foods high in sodium will be beneficial as it provides easy access to useful information. The clear symbols and visuals will provide easy guidance when making informed food products purchased. In addition, this may encourage food industries to improve nutritional quality and value of packaged foods, to ensure adequate sales.
However, as this development is still in the very early stages, progress into a policy requires an extensive period of time for the food industry making these changes on all their products. Moreover, this policy implementation appears to over-value certain nutrients, and these symbols may not be enough to discourage consumers from purchasing processed foods high in sodium and fat (9).
5.Articulation of Policy Area明确政策范畴
High rates of disability and morbidity in Canada are due to the development of chronic diseases partially as a result of poor nutrition. A key contributor to these chronic health conditions is high sodium consumption. Since most Canadians now consume 1100mg/d more than the required daily intake (2300mg/day), managing comorbidities has become increasingly difficult in the last century. It is estimated diagnoses of high blood pressure is present among roughly 25% of Canadians, over the age of 20 (17, 18). High sodium consumption among Canadians contributes to one third of these cases (14). Overall, high sodium consumption can result in stomach cancer, impaired kidney function, and osteoporosis (17, 19). Pre-packaged processed foods contribute to high levels of sodium (in addition to fat and sugar) intake among Canadians (1,14, 18). This paper will be primarily focusing on the policies surrounding sodium levels in processed foods.
加拿大的高残疾率和发病率是由于营养不良造成的慢性疾病的发展。导致这些慢性健康问题的一个关键因素是高钠摄入量。由于大多数加拿大人现在的摄入量比每日所需摄入量(2300mg/天)多1100mg/天，在上个世纪，管理合并症变得越来越困难。据估计，在20岁以上(17,18岁)的加拿大人中，约有25%的人被诊断患有高血压。三分之一的病例是加拿大人的高钠摄入量造成的(14)。总的来说，高钠摄入会导致胃癌、肾功能受损和骨质疏松症(17,19)。加拿大人摄入的预包装加工食品中钠(除脂肪和糖外)含量较高(1,14,18)。本文将主要关注有关加工食品中钠含量的政策。
It is important to note social, personal, economic factors and sustained quality of life requires good health and well-being. A healthy and productive society decreases the burden on the health care system and improves the economy. In addition, a safe and nutritious food supply is vital to overall health and well-being of individuals.
Enabling food/nutrition sector changes requires the involvement of eager administrators and policy-makers. Decision-makers support an inter-sectoral approach when superior sectors (federal government) emphasize the importance of nutrition policies regarding public health.
6.Challenges Encountered遇到的挑战
It can be difficult to introduce public health nutrition policies (specifically sodium reduction) at the provincial level, as several changes are introduced to the health protection legislation and public health systems involved (16). Initiating large institutional changes such as nutrition policies, requires consideration of the extensive range of individuals involved, and multiple economic resources required. Also, changes such as sodium reduction, food labelling, or fortification of milk require extensive effort and long periods of time to introduce, establish and maintain. As a result, research is needed to prove that sodium should be reduced in, for example, processed food. Such research involves significant resources (people, money, etc.), and can be very time consuming, often requiring several years.
在省一级推行公共卫生营养政策(特别是减少钠摄入量)可能很困难，因为涉及的健康保护立法和公共卫生系统已经进行了一些改变(16)。发起诸如营养政策等大型体制改革，需要考虑到所涉及的个人的广泛范围和所需的多种经济资源。此外，诸如减少钠含量、食品标签或强化牛奶等改变需要大量的努力和长时间来引入、建立和维持。因此，需要研究来证明钠应该减少，例如，加工食品。这类研究涉及大量资源(人员、资金等)，可能非常耗时，通常需要数年时间。
Nutrition policies surrounding sodium reduction in Ontario are a small subset of the broad policy area of public health nutrition. Controlled at both the federal and provincial level, there are multiple governing bodies that promote, establish and monitor nutrition policies. This policy area falls under the legislative framework of many acts, including the Food and Drug Act. However, there are no provincial regulations relating specifically to sodium reduction of processed foods. There are many challenges that need to be combatted to effectively work towards mandatory (not voluntary) targets for sodium reduction in processed foods. Effective sodium reduction policies are important in working towards improving the health, well-being of the community and reducing the healthcare system budget.
在安大略省，围绕着减少钠的营养政策是公共健康营养广泛政策领域的一小部分。在联邦和省两级的控制下，有多个理事机构促进、制定和监测营养政策。这一政策领域属于许多法案的立法框架，包括《食品和药物法案》。然而，目前还没有专门针对加工食品减少钠含量的省级法规。为了有效地实现在加工食品中减少钠的强制性(而非自愿性)目标，还需要应对许多挑战。有效的减钠政策对于改善社区的健康、福利和减少医疗保健系统预算十分重要。
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