Journal of Agricultural and Environmental Ethics (2007) 20:247–259 DOI 10.1007/s10806-007-9033-1
Springer 2007 DORIS SCHROEDER

PUBLIC HEALTH, ETHICS, AND FUNCTIONAL FOODS (Accepted in revised form November 4, 2006)

ABSTRACT. Functional foods aim to provide a positive impact on health and well-being beyond their nutritive content. As such, they are likely candidates to enhance the public health officialÕs tool kit. Or are they? Although a very small number of functional foods (e.g., phytosterol-enriched margarine) show such promise in improving individual health that Dutch health insurance companies reimburse their costs to consumers, one must not draw premature conclusions about functional foods as a group. A large number of questions about individual productsÕ safety, efficacy, and affordability need to be answered before they might become an important part of the public health agenda. More importantly, though, the costs and benefits of functional foods relative to alternative mechanisms of public health improvement need to be ascertained. Alternative scenarios that warrant investigation are mainly the supply of nutraceutical ingredients in pill form targeting ‘‘at risk’’ groups and consumer education on diet and lifestyle. KEY WORDS: ethical matrix, food ethics, functional foods, nutrition, public health The next time you feel like complaining, remember that your garbage disposal probably eats better than 30 percent of the people in the world. Robert Orben [US screen-writer] I’ve been on a constant diet for the last two decades. I’ve lost a total of 789 pounds. By all accounts, I should be hanging from a charm bracelet. Erma Bombeck [US humorist, 1927-1996]

1.

INTRODUCTION

Public health can be defined as ‘‘the collective action by a community or society to protect and promote the health and welfare of its members’’ (Duffy, 1995: 2157). The discipline, which evolved with urbanization and secularization,1 promotes general population health via three main avenues: 1) provision of medical services for all; 2) securing a healthy environment; 1

"In a world where sickness and accidents were attributed to spirits, the welfare of the tribe and its individual members depended upon paying proper homage to the spiritual realm" rather than providing medical resources and aiming for a healthy environment and healthy conduct in the modern sense (Duffy, 1995: 2157).

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and 3) encouraging health-conducive behavior, for instance through education (Breslow, 1995: 2154). Currently accepted public health policies go considerably beyond those a liberal would accept (Mill, 1982). Free medical services, rat control, seat belt regulations, vaccination, sex education, food provision for the poor, water fluoridation, cancer screening, ban on alcohol advertisements are all public health measures that would have been unimaginable a century ago (and still are, in large parts of the world). Which measures are acceptable and which are not has been discussed widely in philosophical literature.2 What about functional foods? Could they be a valuable element of the public health officialÕs tool kit? The term ‘‘functional food’’ was introduced by Japanese researchers more than twenty-five years ago, but the concept still defies uniform definition. The first book on the topic (Goldberg, 1994) spoke of ‘‘any food that has a positive impact on an individualÕs health, physical performance, or state of mind in addition to its nutritive values.’’ In other words, in addition to the bulk ingredients and calories that one consumes when eating a food, a functional food has to deliver an additional beneficial effect on health or well-being. Phytosterol-enriched margarine, for instance, provides all the nutrients (and fat...) of traditional margarine, but in addition can reduce cholesterol levels.3 Within Europe, a joined definition was introduced in 1999, namely (Diplock et al., 1999: 6): Food can be regarded as ‘‘functional’’ if it satisfactorily demonstrated to beneficially affect one or more target functions in the ‘‘body’’, beyond adequate nutritional effects, in a way that is relevant to either an improved state of health and well-being and/or reduction of risk of disease.

Speaking in Codex Alimentarius legal terms, effective functional foods could avail themselves of two types of health claims: (a) the enhanced function claim (e.g., ‘‘will improve your immune system’’) or (b) the reduction of disease risk claim (e.g., ‘‘will reduce your risk of developing heart disease’’). Although these claims are not yet allowed in the European Union, foods with the above effects should be of great interest to the public health official. An answer to the question whether functional foods are indeed a useful tool for the public health official, can be provided on two levels. First, one 2

For the general discussion about liberty versus paternalism in public health, see Ronald Dworkin (1977) Taking Rights Seriously. Harvard University Press, Massachusetts, US. (R. Dworkin argues that certain public health measures threaten the autonomy of individuals and are insulting in the process). Also, Gerald Dworkin (1972) ‘‘Paternalism,’’ Monist, 56:1, 64–84 and Joel Feinberg (1973) Social Philosophy. Prentice-Hall, Englewood Cliffs, US. (G. Dworkin and Feinberg argue that public health measures are only weakly paternalistic and can be justified on utilitarian grounds). 3 For more information, see below.

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can present currently available scientific evidence and proceed to a conclusion. Second, one can provide a framework for answering the question from an ethics perspective. In the latter case, the scientific response would still have to be provided, but could be better informed. Proceeding in this manner, I shall look at two related topics with an emphasis on the second. 1) How could functional foods contribute to the public health agenda?4 2) What are the ethical issues––broadly understood––surrounding functional foods and how do these relate to public health? 2.

FUNCTIONAL FOODS AND PUBLIC HEALTH

In 2002, 57 million people died around the world. The three leading causes of death were coronary heart disease (7.2 million = 13%), cancer (7.1 million = 12%), and stroke (5.5 million = 10%) (Mackay and Mensah, 2004: 53). All above named causes of death, but particularly coronary heart disease and stroke, are linked to over-consumption (in contrast to other causes of mortality such as diarrhea or tuberculosis). The overconsumption of fatty processed foods, high in refined sugars, low in vitamins and minerals, in conjunction with a sedentary life-style can lead to high blood pressure, high cholesterol levels, obesity, atherosclerosis, and, eventually, coronary heart disease and stroke. In this context, it comes as no surprise that public health strategists in Europe aim to reduce the burden of non-communicable disease by effecting changes in diet and life-style. In the UK, for instance, the two top goals of the most recent strategy paper Saving Lives: Our Healthier Nation (Department of Health, 1999) are (1) to reduce the death rate from cancer in people under 75 by at least one fifth by the year 2010 and (2) to reduce the death rate from coronary heart disease and stroke in people under 75 by at least two fifths by the year 2010. The report notes that diet accounts for about a quarter of cancer deaths in the United Kingdom (ibid. 5.10), and that deaths from coronary heart disease and stroke could be reduced considerably, if fat and salt intake were decreased, and fruit and vegetable intake increased. None of this will come as a surprise to the reader. But staying with the UK example for the moment, the problem seems to be that the ‘‘UK public appears resistant to Government advice on aspects of life-style that they consider to be matters of personal choice, e.g., smoking and diet’’ (Mathers, 2000: S212). Not only that, resistance can even crystallize to defiance, as in the case of FOREST (Freedom Organisation for the Right to Enjoy 4 In this article, I shall not deal with the topic of food and public health in relation to genetic factors. For a good overview article, see Chadwick, Ruth (2004) ‘‘Nutrigenomics, individualism and public health,’’ Proceedings of the Nutrition Society, Vol. 63, pp. 161–6.

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Smoking Tobacco), ‘‘a little taste of heaven for smokers and tolerant nonsmokers!’’5 The awareness amongst the general public about the health effects of fatty foods has become very high, but this has not translated into significant changes in dietary behavior (ibid.). Could functional foods fare better than educational campaigns in an attempt to reach public health goals of reducing non-communicable diseases of over-consumption? If one looks at selective examples and applies common sense reasoning, one would expect so. It has already been mentioned that cholesterol levels can be reduced by phytosterol-enriched margarine. The mechanics of this process are fairly straightforward. Phytosterols are plant compounds that are similar to cholesterol in their molecular structure. This means that they compete with cholesterol for intestinal uptake. If one consumes cholesterol (e.g., in crisps) around the same time as phytosterol margarine, both will try to be absorbed by the body. Due to the competition, the uptake of cholesterol will be diminished and in the medium term cholesterol levels reduced. Two to three g phytosterols taken on a daily basis can reduce LDL-cholesterol levels (‘‘bad cholesterol’’) by 10–14% in different populations (Chadwick et al., 2003: 189). The Framingham Heart Study showed a link between cholesterol levels and heart disease as early as 1961, and other studies (e.g., the Lipid Research Clinics-Coronary Primary Prevention Trial (1984)) confirmed that lowering LDL-cholesterol levels significantly reduced the risk for heart disease. According to the above cited British Saving Lives report, a 10% reduction in cholesterol levels lowers the risk of coronary heart disease by 50% at age 40 falling to 20% at age 70. Let us remind ourselves of the British governmentÕs public health goal in connection with coronary heart disease. The aim is to reduce the death rate from coronary heart disease and stroke in people under 75 by at least two fifths (=40%) by the year 2010. This looks as a reasonable chance (ranging from 20 to 50%) of lowering the risk of coronary heart disease without any life-style changes, except the replacement of one margarine with another? Let us look at ethical implications first before jumping to any conclusions, though. 3.

FUNCTIONAL FOODS AND ETHICS

Food is fundamental to human existence. It is essential for survival, health, and well-being; it carries strong spiritual-symbolic significance (e.g., Buddhist vegetarianism) and it helps to form and maintain social relationships (e.g., family dinner). Thus, it is unsurprising that food is intimately bound 5

About FOREST, at: http://www.forestonline.org/output/Page103.asp, accessed 4 July 2005.

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up with ethics, the study of norms, principles, or values that ought to guide human action. For instance, starvation and malnutrition pose some of the oldest questions about the duties of beneficence towards strangers. In addition to the issue of global hunger, food ethics faces a series of new questions that only emerged with the introduction of modern agricultural practices and biotechnologies. Is the exploitation of animals associated with intensive farming ethically acceptable? Do modern technologies produce safe, nutritious, and good quality food? Is food marketing ethically sound? Does the modern production of food have detrimental effects on the environment in terms of soil erosion, loss of biodiversity, and pollution? (Mepham, 1996: xi) Or on a more general level: Where does state responsibility for citizen nutrition start and stop? Ought the health system to adopt punitive measures for those who put their health at risk through junk foods? With regard to functional foods, the most important ethical questions are summarized in the following Table 1.6 Table 1. Ethical matrix Principles Stakeholders

Utility

• Food safety • Food Efficacy • Quality of life Economic Activity • Satisfactory income (Agriculture, and working conditions Manufacturing, • Commercial viability Services, • Public health effects Distribution) Non-human • Animal welfare stakeholders • Environmental Sustainability

Consumers

6

Rights

Fairness

• Informed choice • Affordability (and voice) and Availability (access) • Freedom (not)/ • Fair laws to adopt (fair regulations • Equal for health claims) • Opportunities

The table is based on the principle of the ‘‘ethical matrix,’’ which is widely used within interdisciplinary expert groups and public consultations (developed by Ben Mepham, see also B. Mepham (ed.), Food Ethics (London: Routledge, 1996)). A similar table about the ethics of functional foods was discussed and adopted during expert committee sessions mentioned in the acknowledgements. The table was first published and justified in Chadwick et al., 2003: 143, but modified slightly for this publication. For constructive criticism of the Ethical Matrix, see D. Schroeder and C. Palmer, ‘‘Technology Assessment and the ‘‘Ethical Matrix,’’ Poiesis and Praxis 1(4) (2003), pp. 295–307.

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All of the questions raised by the ethical matrix are important, but in the context of public health, a sub-set of four are the most significant, namely7: a) b) c) d)

Are functional foods safe? Are functional foods effective? Are functional foods sufficiently known? Are functional foods affordable?(Please remember that we are setting out a framework for answering the question of whether functional foods are useful for the public health official. Invariably this includes raising questions to which scientific answers are required).

The above four concerns are not of equal value, instead their importance decreases by moving down the list. Let us assume we have a functional food product (x), which is believed to provide positive health benefits and thereby the potential to increase public health on the macro-level. The worst scenario would be that (x) is in fact unsafe and instead of benefiting consumers harms them. We would have achieved the exact opposite of what we wanted and spent scarce resources in the process. The second worst scenario is that (x) is ineffective. Given that functional foods with nutrition or health claims are usually more expensive than their traditional equivalents, this would amount to money being spent on a presumed health goal that could have been spent more wisely. If we have a functional food (x), which is safe and effective, and therefore has the potential to lead to an improved state of health and well-being, two main barriers remain: first, those who could benefit from it, might not know about its existence and / or functions; second, those who could benefit from it, might not be able to afford or obtain it. Access questions are secondary to knowledge questions, as one first needs to learn about a product before understanding the need to access it. So, what could be said about the four questions raised? 3.1.

Safety

By asking a nutritionist, even one specializing in functional foods, ‘‘Are functional foods safe?’’ one could probably provoke a frown. It is simply

7 One could argue that the right to make informed choices has an impact on public health. However, I take this impact to be either of an indirect nature or to be covered by the questions below. For instance, if informed choice leads to the avoidance of unhealthy foods, this has a clear public health implication, but it is also covered by the safety question. The same applies to, for instance, special nutritional needs. It is unsafe for a sufferer of nut allergies to consume peanuts. Where informed choice leads to the avoidance of certain products as a matter of taste, no direct public health implication can be inferred.

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impossible to answer this question with a single statement. The variety of functional foods ranges from probiotics, which in the case of Yakult has been on the market with no major safety issues since 1955 (Heasman and Mellentin, 2001: 131) to GM-modified ‘‘golden rice,’’ which has not yet gone beyond the trial stage and to which organizations such as Greenpeace are violently opposed (Kiehl, 2001: 9). In addition, the question of safety does not only require a look at individual products separately, but also at individual consumer groups. A product that might be safe and beneficial for one consumer, might be dangerous for another one. For instance, vitamin E can significantly worsen the health of consumers who have a vitamin K deficiency and lead to problems with blood clotting (Menrad et. al 2000: 70). Hence, the public health question with regard to the safety of functional foods has to be, ‘‘Are adequate mechanisms in place to distinguish safe from potentially unsafe functional foods and will these mechanisms ensure that ill effects that only affect minorities (e.g., those with certain food allergies) will be detected?’’ The safety question can only be answered for one product or one active ingredient at a time. 3.2.

Efficacy

In scientific research, efficacy is usually distinguished from effectiveness, the former measuring the desired effect under ideal conditions, the latter measuring the effect on a population at large under average conditions (Plaami et al., 2001: 20). I shall use the term ‘‘efficacy’’ more broadly to encompass both. Do functional foods work or are they no more than an expensive alternative to the traditional product with no added benefits? Are markers used to measure their efficacy reliable? How much of the active ingredient is still available at the time of consumption? Will storage, transport, and shelflife put into question initial results obtained in the laboratory? And how does one deal with the problem of dosage? To have an effect, functional foods must normally be eaten on a regular basis at optimal levels. There are several questions that pose themselves: What does regular imply? What is the optimal dosage and are there any upper limits beyond which the product is not safe? Will consumers comply with dosage prescriptions for food? Food is not medicine (although the boundary is becoming blurred). Also, are functional foods beneficial for healthy consumers, e.g., if one has a well functioning microflora does one still benefit from probiotics? Yet again, the public health question with regard to the efficacy of functional foods has to be, ‘‘Are adequate mechanisms in place to distinguish effective from potentially ineffective functional foods and will these mechanisms ensure that claims are well founded?’’

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Awareness

One serious hindrance to achieving optimal public health effects is lack of consumer awareness and knowledge about functional foods or negative consumer attitudes. According to Belgian research, 49% of the Belgian population claim to understand the concept of functional foods, a figure that is higher than in other European countries (Verbeke and Viaene, 2001: 401f). Accordingly, at least 50% of the population are excluded from potential benefits, simply because they are not aware of product availability. Those who are aware of functional foods might not be inclined to buy them for various reasons. For instance, 33% of the Belgian sample argued that functional foods were too expensive, 21% believed that functional foods were not suitable for a natural way of life, whilst 6% considered functional foods as not beneficial for their future health (ibid. 402). New research has even shown that Belgian consumers grew more critical of functional foods in the time from 2001 to 2004. Belief in the significance of food for health increased, whilst belief in the potential health benefits from functional foods decreased! (Verbeke, 2005 and 2006). To achieve full public health benefits, positive attitudes and knowledge about functional foods are important. If a significant number of functional foods proved safe and highly effective, an important question for the public health official would be whether consumer awareness and acceptance campaigns were warranted to promote them in comparison to other campaigns (e.g., 5 a day http:// www.5aday.nhs.uk/). 3.4.

Access

In my local supermarket, prices for margarine range from 0.12 Euro to 1.20 Euro per 100 g (phytosterol-enriched margarine). Thus, phytosterolenriched margarine is exactly ten times as expensive as the cheapest equivalent. Are phytosterol margarines and other functional foods a health food for the affluent? In order to supervise inflation, statisticians calculate the prices for the so-called ‘‘basket of goods’’ every year. One can imagine this to be a shopping basket with goods and services that fulfill most needs of citizens: food, clothes, rent or mortgage, leisure expenses, furniture, health, transport, education etc. The content of the basket is kept stable, so that new calculations reveal the yearly changes in prices. In Germany, the percentage of food-related expenses has dropped extraordinarily since the 1950s, as the following diagram shows (Statistisches Landesamt, 2002 and 2006). (Figure 1) Only 14.0% of the expenses of the 2005 basket relate to food, drink, and tobacco, in contrast to 53.2% in 1950. At the same time, expenses for

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Basket of Goods, 1950-2005, Germany 100% 80% Expenses

Food & drinks

60%

Housing

40% 20%

Other

0% 1950

1995

2005

Figure 1. Chadwick et al. (2003, p. 143), modified slightly for this publication.

housing have more than doubled as a percentage of total costs, from 10.2% in 1950 to 24.4% in 2005. This is not the place for a detailed statistical examination of baskets of goods. However, one point becomes clear. Income spent on food is shrinking across households, whether because of the changing readiness to spend money on food, the increased efficiency in food production, or because other items in the basket are becoming significantly more expensive. To expect particularly low-income households, to be able to afford high-priced functional foods is unrealistic. In this regard, functional foods are for the rich and educated, as we have seen before. And this creates two problems for the public health official, if one assumes that individual functional foods are safe and effective. 1) A group of citizens is excluded from the benefits of such foods due to their high prices. 2) A mismatch can occur between those consuming functional foods and those who are most likely to benefit from them. According to a Swiss study, a serious mismatch between consumers of functional foods and those who would most benefit from them can already be observed. Functional foods are most attractive to well-educated women between 30 and 50 (Menrad et al., 2000: 191). ‘‘SheÕs elite, informed and educated’’ (Childs, 2002) is how functional food consumers were described within the US food market context. However, young and middle-aged women are one of the least likely groups to need functional foods, whilst children and the non-affluent elderly (ibid. III), as well as consumers in the developing world would benefit the most (Heasman and Mellentin, 2001: 266). However, those groups who would benefit the most are not target groups of producers and marketing strategists, as their financial situation is not attractive enough. Some Dutch health insurance companies have decided to reimburse the extra costs of phytosterol-enriched margarine up to a maximum of 40 Euro per year. To do so, subscribers have to send in the barcodes of the product (VGZ 2005). But from a public health perspective, the question remains:

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Assuming functional foods proved as conducive to good health and wellbeing as their definition maintains, how can the right people be helped to consume the right functional foods, when both lack of education and affordability create serious barriers to access? 3.5.

Functional Foods – A Techno-Fix?

The questions raised in the context of safety, efficacy, awareness, and affordability are all questions from within the functional food framework. In other words, one could say they look at functional foods with tunnel vision or without a meta-perspective, as assessment is not undertaken in comparison with other parts of the public health officialÕs tool kit. And, of course, functional foods are not greeted everywhere as the big idea of the 21st century, but are also described as 21st century quackery (Heasman and Mellenti, 2001: xv, xvii). The following is a recommendation from an expert commission, of which I was a member, which I would strongly underline (Chadwick et al., 2003: 12): It is essential for public health officials to ascertain the costs and benefits of functional foods relative to alternative mechanisms of public health improvement.... Substantial evidence has to be gathered on whether the support of functional foods by public health measures would be the best way to use scarce resources. Two alternative scenarios that warrant investigation are: 1) supply of nutraceutical ingredients in pill form aimed at ‘‘at risk’’ groups and 2) consumer education on diet and lifestyle. Developing new functional food products to fight obesity or diabetes type 2, for instance, could be regarded as a ‘‘technical fix’’ with a preference given in the first place for prevention of those diseases through well-balanced, healthy diets and exercise.

In this context, it is also enlightening to look at potential functional foods of the future, which––one assumes––will be based on functional food ingredients, which have already been identified. The International Food Information Council (2004) lists, for instance, see Table 2. For most of these components, nutritionists will not think of processed foods, but rather of ‘‘traditional’’ foods: carrots for beta-carotene, tomatoes for lycopene, wheat bran for insoluble fiber, certain types of fish for omega– 3 fatty acids, some green fruits and vegetables for flavonals; and only in the context of free stanols/sterols and probiotics does one think of processed products. From a public health perspective, it is essential that functional foods are weighed considerately with satisfactory evidence against other types of diets. At the outset of the article, I chose phytosterol-enriched margarine as an example of how functional foods might suit the public health officialÕs

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Table 2. Functional food components and their associated potential health benefit Functional food component

Potential health benefit

Beta-carotene Lycopene

Neutralization of free radicals May contribute to maintenance of prostate health May contribute to maintenance of a healthy digestive tract May reduce risk of coronary heart disease Neutralization of free radicals May reduce risk of coronary heart disease May improve gastrointestinal health and systemic immunity

Insoluble fiber PUFAs - Omega-3 fatty acids Flavonols Free Stanols/Sterols Lactobacilli, Bifidobacteria

agendas. However, it has to be stressed that––together with probiotics–– phytosterols are still rather unique in providing the potential for a health benefit that is (a) comparable to the intake of nutraceuticals or drugs and (b) not easily achievable with traditional food. One should not draw the wrong conclusions about the health benefits of functional foods as a group from the health potential of phytosterol margarine. 4.

CONCLUSION

Functional foods aim to provide a positive impact on health and well-being beyond their nutritive content. This makes them highly attractive to the public health official. However, there are too many unanswered questions about functional foods to recommend them as an effective device in the public health officialÕs tool kit. Although a very small number of functional foods (e.g., phytosterol-enriched margarine) show such promise in improving individual health that Dutch health insurance companies reimburse their costs to consumers, one must not draw premature conclusions about functional foods as a group. A large number of questions about individual productÕs safety, efficacy, and affordability need to be answered before they might become an important part of the public health agenda. More importantly, though, the costs and benefits of functional foods relative to alternative mechanisms of public health improvement need to be ascertained. Alternative scenarios that warrant investigation are mainly the supply of nutraceutical ingredients in pill form targeting ‘‘at risk’’ groups and consumer education on diet and lifestyle.

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ACKNOWLEDGEMENTS I would like to thank Dr. Angus Dawson for inviting me to present this paper at ‘‘Food, Ethics and the PublicÕs Health,’’ organized by the Center for Law, Ethics and Society at Keele University in June 2005. I would also like to thank participants for very useful comments, Franck Meijboom and Peter Aggett for valuable information, two anonymous reviewers for excellent suggestions for improvements and Armin Schmidt and Angus Dawson for comments on an earlier draft.

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