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CarolineCaroline’’s Careers Career•• Schooling: 1961Schooling: 1961--68: Cheltenham Ladies College68: Cheltenham Ladies College•• VSO: Convent of Nazareth, Haifa, Israel VSO: Convent of Nazareth, Haifa, Israel •• 19691969--72: BSC Biology Queen Eliz Coll. London72: BSC Biology Queen Eliz Coll. London•• Science Editor: Amsterdam & Israel travelScience Editor: Amsterdam & Israel travel•• 1977&78 MSc LSHTM Theses on poverty and 1977&78 MSc LSHTM Theses on poverty and
on on VitVit. D in Asians and the elderly. D in Asians and the elderly•• 19791979--80 Nutritionist. MRC Unit in Cardiff80 Nutritionist. MRC Unit in Cardiff•• 1980 1980 –– 1982 Nutritionist MRC Dunn, Cambridge1982 Nutritionist MRC Dunn, Cambridge•• 1983 1983 ––1986. Community Nutritionist, Hackney1986. Community Nutritionist, Hackney•• 1983 1983 ––1988 Campaigner, author; CPG Secretary 1988 Campaigner, author; CPG Secretary •• 1988 September 221988 September 22nd nd died aged 38died aged 38
The NACNE committeeThe NACNE committee•• 1979 Established: Chair Prof. Jerry Morris1979 Established: Chair Prof. Jerry Morris•• Representatives: DHSS, MAFF, Health Representatives: DHSS, MAFF, Health
Education Council, British Nutrition Foundation, Education Council, British Nutrition Foundation, Scottish, Welsh &N. Ireland Health Education Scottish, Welsh &N. Ireland Health Education reps; Food Industry.reps; Food Industry.
•• Sub group established to consider general Sub group established to consider general nutritional advice for the British public ; initial nutritional advice for the British public ; initial request was to provide advice only for special request was to provide advice only for special subsub-- groups e.g. in Gujarati and other languages groups e.g. in Gujarati and other languages on the need for Vitamin D in Asian adolescents on the need for Vitamin D in Asian adolescents and women.and women.
Major developments of the last Major developments of the last 20years20years
•• Nutrition as key to public health became acceptedNutrition as key to public health became accepted•• Battles continued: WHO 797 1990 reportBattles continued: WHO 797 1990 report•• 1994 Scottish diet report and Ministerial Action report 1994 Scottish diet report and Ministerial Action report
ignored in England ignored in England •• 1995 : D of H obesity prevention report watered down 1995 : D of H obesity prevention report watered down •• 1996 BSE identified as cause of vCJD 1996 BSE identified as cause of vCJD •• 1997: Food Standards Agency proposed1997: Food Standards Agency proposed•• 1997 WHO Obesity report delayed; ILSI pays WHO 1997 WHO Obesity report delayed; ILSI pays WHO •• 1997 ILSI induced FAO Carbohydrate report: later 1997 ILSI induced FAO Carbohydrate report: later
rejected and rewritten in relation to both sugar and fibre.rejected and rewritten in relation to both sugar and fibre.•• 1998 : D of H Childhood obesity report to new Minister 1998 : D of H Childhood obesity report to new Minister
Public Health Tessa Public Health Tessa JowellJowell rejected rejected -- food industry food industry concernsconcerns
•• 2001: 2001: EurodietEurodiet report battle on sugar, salt & report battle on sugar, salt & breastfeedingbreastfeeding
WHO initiatives for action on chronic diseases
First presentation of the major risk factors
explaining the burden of sickness and early death
across the world
2002 2003
The update on the evidence on diet
and physical activity in relation
to chronic diseases
2004
The Member State agreed WHO Global strategy on diet and
physical activity
The ten leading causes of death in Low and Middle / High income The ten leading causes of death in Low and Middle / High income countriescountries Low- and Middle-income countries High-income countries
Cause
Deaths (millions)
% total deaths Cause
Deaths (millions)
% total deaths
1. Ischemic heart disease
5.70 11.8 Ischemic heart disease
1.36 17.3
2. Cerebrovascular disease
4.61 9.5 Cerebrovascular disease
0.76 9.9
3. Lower respiratory infections
3.41 7.0 Trachea, bronchus & lung cancers
0.46 5.8
4. HIV/AIDS 2.55 5.3 Lower respiratory infections
0.34 4.4
5. Perinatal conditions 2.49 5.1 Chronic obstructive pulmonary disease
0.30 3.8
6. Chronic obstructive pulmonary disease
2.38 4.9 Colon and rectal cancers
0.26 3.3
7. Diarrhoeal diseases 1.78 3.7 Alzheimer's & other dementias
0.21 2.6
8. Tuberculosis 1.59 3.3 Diabetes mellitus 0.20 2.6
9. Malaria 1.21 2.5 Breast cancer 0.16 2.0
10 Road traffic accidents 1.07 2.2 Stomach cancer 0.15 1.9
WHO / World Bank. Global Burden of Disease. Lopez et al., 2006. Amplified by excess weight gain
-2 0 2 4 6 8 10
Smoking
High blood pressure
Overweight & obesityHigh cholesterol
Alcohol usePhysical inactivity
Low fruit & veg. intake
Illicit drug useUnsafe sex
Iron deficiency anemia
Attributable disease burden (% regional DALYs; total 149 million)
The top risk factors underlying the disease burdenThe top risk factors underlying the disease burdenof high income countries (all preventable)of high income countries (all preventable)
WHO / World Bank. Global Burden of Disease. Lopez et al., 2006.
Lifecycle: the proposed causal links
Higher maternal mortality
Reduced mental
capacity
Reduced capacity to
care for baby
Inadequate foetal
nutrition
Higher mortality
rate Impaired mental development
Untimely / inadequate Weaning
Frequent infections Inadequate food,
health & care
Inadequate growth
WomanMalnourished
PregnancyLow Weight
Gain AdolescentStunted
ChildStunted
Elderly Malnourished
BabyLow Birth
Weight
Inadequate food, health & care
Inadequate food, health & care
Reduced mental
capacity
Inadequate food, health
& care
Epigenetic susceptibility to chronic diseases if diet becomes inappropriate
Adapted from James et al. SCN Millennium Rep. Food & Nutrition Bulletin, 2000, 21, 3S.
The impact of inappropriate Western diets on most of the world'ssusceptible populations: health systems already overwhelmed
Adapted from James et al. SCN Millennium Rep. Food & Nutrition Bulletin, 2000, 21, 3S.
Early onset Type 2
Diabetes
Reduced play and
social isolation
Reduced capacity to
care for baby
Disordered foetal
nutrition
Untimely / inadequate Early Weaning
Frequent fast foods
Inadequate physical activity
Normal/high growth
Womano/w or obese Pregnancy
Glucoseintolerance/
diabetes AdolescentO/W-obese
Child overweight
Elderly
Diabetes, strokes,
heart disease, cancersarthritis
Fat BabyHigh Birth
Weight
Poor school conditions
Inadequate obstetric care
Reduced job opportunities
Inadequate health care
system
Abdominalobesity
RapidRapid weight gainweight gain
Reduced fertility; CVD, HT Cancers
British wartime feeding based on novel nutritional conceptsBritish wartime feeding based on novel nutritional concepts
Milk
Cod liver oil
Orange juice
The transformation of agriculture: an issue of The transformation of agriculture: an issue of fundamental national securityfundamental national security
The Traditional Mediterranean Diet
Corfu & Crete1960-65 Men (7
country) g/d
S. Italy1930s Household
(CNR) per caput g/d
EURATOM1960s Household
g/d/consumption unit
S. Italy1960-65 Men (7
country) g/d
0
250
500
750
1000
1250
1500Fish
Fruit
Vegetables
CerealsFats & oils
Milk
Meat
EggsAlcohol
Sugars etc.
Gra
ms
Compiled by Anna Ferro-Luzzi Institute of Nutrition Rome
A quarterA quarter--pound cheeseburger, pound cheeseburger, large fries and a 16 oz. soda large fries and a 16 oz. soda provide:provide:
1,166 calories 1,166 calories 51 g fat 51 g fat 95 mg cholesterol95 mg cholesterol1,450 mg sodium1,450 mg sodium
The fall in the global cost of agricultural commodities The fall in the global cost of agricultural commodities 19601960--20002000
Based on 1990 world market prices. Source: World Bank, 2001.
Agriculture (index)
Food (index))
Maize (US$/tonne)
Palm oil (US$/tonne)
Rice (US$/tonne)Soybean
(US$/tonne)
Wheat (US$/tonne)
Index, 1990 = 100Constant 1990 US$/tonne
Government support for producing grain and oilseed crops comes in many forms, from money invested in public universities and government agencies to research such crops, to subsidy payments that make up for low prices, to continued promises of increased export markets for these crops.
Foods Foods contributing contributing to average to average global energy global energy intakesintakes
Other
Pulses
Roots & tubers
Meat
Sugar
Vegetable oils
Other cereals
Wheat
Rice
kcal
/cap
ita/d
ay)
1964-66 1997-99 2030
3,000
2,500
2,000
1,500
1,000
500
0
Source: FAO data and projections
0
200
400
600
800
1000
0.01 0.1 1 10 100 1000Energy cost (Euros/1000kcal)
Ener
gy d
ensi
ty (k
cal/1
00g)
oil
butter
sugar
desserts
milk
grainscheese
fruit
fish/shellfish
vegetables
nuts
pasta
Log scale!
High energy dense foods (kcal / 100g) cost less (High energy dense foods (kcal / 100g) cost less (€€ / 1000 kcal)/ 1000 kcal)
Darmon, Darmon, Maillot and Drewnowski, JADA, 2005
The keys to success in the food business The keys to success in the food business and in obesity and chronic disease and in obesity and chronic disease
preventionprevention
•• PricePrice
•• AvailabilityAvailability
•• MarketingMarketing
The current obesity dilemma:The current obesity dilemma:
Obesity is a normal "passive" biological response to our changed physical and
food environment
Some children/adults are more susceptible for genetic, social and
economic reasons
Overwhelming environmental impact reflects outcome of normal
industrial development
Obesity reflects failure of the free market
UK Government report Oct. 2007
The current obesity dilemma:The current obesity dilemma:Obesity similar to climate change:
1. Outcome of numerous societal and industrial developments/ forces
2. Action now essential- exceptionally difficult to reverse
3. No single remedy will suffice
4. Co-ordinated central & local government, industrial, societal and individual changes necessary
5. Major changes needed - not just individual advice to eat less and walk more!
6. Immediate action necessary although many logical remedies remain unproven
UK Government Report Oct.2007
2%
1%
0%0-1000 1000-
15001500-1820
1820-1998
Annualised Per Caput World GDP Growth (Inflation Adjusted)
Maddison : The World Economy: a Millennial Perspective
The interaction of Prosperity, Self Expression and Traditional values
The interaction of Religion, Culture, Self Expression and Traditional values
Trad
ition
al/ S
ecul
ar-R
atio
nal D
imen
sion
s
Survival/ Self expression dimension
Survival/ Self expression dimension
Inglehart R, Baker WE “Modernisation, Cultural Change and the persistence of Tradiitonal Values” Amer.Sociol. Rev.2000, 65:29
Global food price index
FAO, 2008
CRB = Commodity Research Bureau yearly index of the spot price in different commodities in the world market; the index is a composite of food, minerals, cloth, steel etc.
Impact of agricultural developments Impact of agricultural developments on climate changeon climate change
• Agricultural sector produces 22% global total emissions
• Livestock production – 80% of emissions (including transport and feed production)
• Propose 90g/d limit meat intake of which <50g from ruminants
• Animal feed focus for grain production requires energy ++
• Diversion of grain for animal use harmful at times of grain shortage
• Fertiliser synthesis costly in oil terms
• Water shortages of huge concern
• Salinity and soil degradation increasing with demand for intensification of land use
McMichael et al. Food, livestock production, energy, climate change, and health Lancet 2007; 370: 1253–63
Economic development and falling food needsEconomic development and falling food needs
3000
2000
1000
Kcals
Car UseMechanical aids
TVComputers
Energy needs
US Intakes
UK Intakes Increasing obesity
Economic development and ageing
? Japan
USA
Adapted from Bray & Popkin, AJCN 1998; 68: 1157-1173 with data from FAO 2005, CFNI and recent national surveys
Dietary fat and weight gainDietary fat and weight gain : additional effects of high : additional effects of high sugar intakes on Caribbean overweight/obesity sugar intakes on Caribbean overweight/obesity
Obesity epidemic is inevitable unless policies to reduce intakes substantially from fat & sugar with spontaneous increases in activity are introduced now
♦
♦
♦
♦
♦
♦
♦
♦
♦ ♦♦
♦
♦
♦
♦
♦♦
Perc
enta
ge B
MI
Perc
enta
ge B
MI >>
25.0
25.0
80
60
50
40
30
20
10
70
Dietary Fat (%) 20 25 30 35 40
Kuwait
Morocco
Philippines
Mali
China 1982
India Congo
TunisiaMalaysia
Australia
New Caledonia
ItalyBrazil
Russia
KyrgyzstanCuba
S. Africa
r = 0.88r = 0.88
♦Barbados
GuyanaTrinidad & Tobago
Jamaica+ 20% sugar
2002
0 1 2 3 4 5 6 7-10-8-6-4-202468
1012141618202224
Time (days)
Ener
gy b
alan
ce (M
J)
High fat
Medium fat
Low fat
0 1 2 3 4 5 6 7-10-8-6-4-202468
1012141618202224
Time (days)
Ener
gy b
alan
ce (M
J)
High fat
Medium fat
Low fat
2.5
1.5
0.5
-0.5
-1.5
-2.5
Weeks
0 2 4 6 8 10
Stubbs et al. Am J Clin Nutr, 1995; 62: 316-329
Catering challenges: increases in hidden fat and sugary Catering challenges: increases in hidden fat and sugary drinks evade appetite regulation and lead to weight gaindrinks evade appetite regulation and lead to weight gain
Raben et al., Am J Clin Nutr 2002; 76: 721-9
Sucrose
Sweetener
Weight changes (kg)
Three groups offered the same food but with very different
amounts of fat show that the groups ate the same volume of food so those on high fat foods unconsciously stored energy
and gained weight
Those adults drinking sucrose containing soft drinks gained weight progressively for 10 weeks; those on calorie free drinks lost weight
Dietary fat & weight gain: a different developing world need
♦
♦
♦
♦♦
Perc
enta
ge B
MI >
25.0
80
60
50
40
30
20
10
70
Dietary Fat (%)20 25 30 35 40
Mali
China 1982
India
Morocco
Guyana
Philippines
WHO suggested limits 15–30% fat
Original Human Diets Western Diets 40+%
♦ Prudent Diets
?Upper limit for most of the world?
Snack Foods Are Everywhere––Car washesCar washes––Book storesBook stores––Hardware stores (Home Depot)Hardware stores (Home Depot)––Gas stationsGas stations––Office buildings (vending machines)Office buildings (vending machines)––Health clubs/gymsHealth clubs/gyms––Video storesVideo stores––Car repair shopsCar repair shops
Doubling shelf space increases sales by 40%Doubling shelf space increases sales by 40%
CHIPS ARE IN SEASON!CHIPS ARE IN SEASON!
Measures attraction to products
Current eyeCurrent eye--tracking technology to detect tracking technology to detect unconscious focus on particular images which unconscious focus on particular images which
then subconsciously affect sales decisionsthen subconsciously affect sales decisionsStill qualifies as "informed free choice"?Still qualifies as "informed free choice"?
HumanHuman--induced soil degradation in the worldinduced soil degradation in the world
Source: Oldeman et al. 1991
Soil degradation types
Stable terrainNon-used wastelandWater bodies
Water erosion
Wind erosion
Chemical deterioration
Physical deteriorationSevere degradation
Other symbols
e.g. Focus on Health Education - but need understandable food labelling; campaigns selectively help upper socio-economic groups
Individual responsibility
Changes to the"toxic" environment
Adapted from Puska P, 2001
Progressively adapt all towns/cities to favour pedestrian/cycling as norm with car restrictionsNutritional standards for food in all government facilities/schools; eliminate trans fats; catering on Finnish scale: fruit + veg. within meal costs Limit/abolish all marketing to children Selectively increase costs of high fat/sugary products; soft drinksSocial/employment/medical policies for breast feeding as the norm
Complementary approaches to obesity & chronic disease prevention
Complementary Complementary approaches to approaches to obesity & obesity & chronic disease chronic disease preventionprevention
Waiting for a green light for health?
Europe at the crossroads for diet and disease
IOTF Position Paper - September 2003
Waiting for a green light for health?
Europe at the crossroads for diet and disease
IOTF Position Paper - September 2003
Waiting for a green light for health?
Europe at the crossroads for diet and disease
IOTF Position Paper - September 2003
Waiting for a green light for health?
Europe at the crossroads for diet and disease
IOTF Position Paper - September 2003
IOTF demand for EU action
Food labelling schemes based Food labelling schemes based on nutritional profiling tested on nutritional profiling tested by the UK Consumers' by the UK Consumers' Organisation Organisation -- "Which""Which"
UK Food Standards Agency scheme
Tesco SupermarketGDA labelling with a different colour for each nutrient
GDA system
Tesco: GDA + traffic lights
Consumer purchases with traffic light food labelling of Consumer purchases with traffic light food labelling of nutrients as proposed by UK's Food Standards Agency. nutrients as proposed by UK's Food Standards Agency. Healthy (green), reasonable (yellow), or unhealthy (red) Healthy (green), reasonable (yellow), or unhealthy (red)
JS Ham & Pineapple Thin & Crispy Pizza 335g
1 red, 2 amber, 2 green
JS Ham and Pineapple Pizzeria 356
all 5 GREEN on WoH
42%55%
Wheel of Health Wheel of Health (WoH)(WoH)
'Taste the Difference' Melting Middle Chocolate
puddings4 red, 1 amber
'Be Good to Yourself' Chocolate sponge
puddings4 Green, 1 amber
42%89%
Sainsbury's Supermarket presentation to The National
Heart Forum, UK., 2006.
Who controls the food chain ? Who controls the food chain ?
Corinna Hawkes, 2006
Local markets, Local markets, roadside stalls roadside stalls and farm shopsand farm shops
Supermarkets: the "food consuming industry"
Small Small food food
outletsoutlets
GENERAL POPULATION
Global Feed CompaniesGlobal Feed Companies
Global Food Companies
Farmers Farmers (large Government subsidies)(large Government subsidies)
Family and other Family and other small food small food companiescompanies
Nutritional profiling determining government policies throughout the food chain
Conclusions:1Conclusions:1Combating tobacco, alcohol, food and physical Combating tobacco, alcohol, food and physical
inactivity problems needs a common theme:inactivity problems needs a common theme:Industry Industry is major driver with major political backing is major driver with major political backing --often controlled by industry: a huge issue public often controlled by industry: a huge issue public health analysts avoidhealth analysts avoidPricePrice of tobacco, alcohol and food has a profound of tobacco, alcohol and food has a profound
effect on consumption patternseffect on consumption patternsAvailabilityAvailability restrictions essential restrictions essential MarketingMarketing by regulatory restriction: stringent controls by regulatory restriction: stringent controls on targeting of :on targeting of :a ) children a ) children b) the poor b) the poor c) the countries in economic transition c) the countries in economic transition –– a huge issuea huge issue
Conclusions:2Conclusions:2Combating tobacco, alcohol, food and physical inactivity Combating tobacco, alcohol, food and physical inactivity
problems needs a common theme:problems needs a common theme:•• Transform WHOTransform WHO’’s approach: use economic issues s approach: use economic issues --
ammunition for Ministers of Healthammunition for Ministers of Health•• Develop economic arguments as the primary mechanism Develop economic arguments as the primary mechanism
of new policy development of new policy development •• Need fundamental new approaches: Need fundamental new approaches: World Bank ; FAO; World Bank ; FAO;
new UNDP concepts for engaging power players at local/ new UNDP concepts for engaging power players at local/ regional levelsregional levels
•• Policy analysis is not enough : Policy analysis is not enough : need public support in need public support in regional subregional sub--national government. Therefore engage civil national government. Therefore engage civil society network of NGOs and other advocates including society network of NGOs and other advocates including carefully selected economic and societal journalists: carefully selected economic and societal journalists:
•• Systematic multiSystematic multi--level changes:level changes: need coherent 5need coherent 5--10 yr 10 yr adaptable plan led by Governmentsadaptable plan led by Governments
•• Industry can helpIndustry can help but need specific regulations & 5 yr but need specific regulations & 5 yr planned changes in policyplanned changes in policy