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Positive Deviance and the Mediterranean Diet and Sustainability Elliot M Berry [email protected] 1 Sustainable Diets case studies: The Mediterranean Diet School Interventions Nutrition the fuel of a Nation Well Fed Nation Food Secure Nation Healthy Nation Productive, Resilient, Sustainable Nation Agriculture, Industry, Human Capital Nutrition, Food Security and Sustainability Agriculture, Imports Food Industry Food Secure Nation Food Loss Food Waste S T A B I L I T Y Well Fed Nation Healthy Nation Productive, Resilient, Sustainable Nation Accessibility Availability Utilization Household Individual National Transport Physical Economic Food Quality, Safety, Sanitation & Health Sustainable Diets SUSTAINABILITY Environment, Economy, Culture GENERATIONS Availability SUSTAINABILITY FOOD SECURITY Socio- Cultural Economy Environment Accessibility Utilization S T A B I L I T Y Natural Resources & Climate Person-Centered Global after Berry et al. Public Health Nutrition, 2015 Sustainable Diets position Sustainability in the Food Security Pathway Sustainable Diets S H O R T T E R M L O N G T E R M
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Positive Deviance and the Mediterranean Diet and Sustainability

Elliot M [email protected]

1

Sustainable Dietscase studies:

The Mediterranean Diet

School Interventions

Nutrition the fuel of a Nation

Well Fed Nation

Food Secure Nation

Healthy Nation

Productive, Resilient,

Sustainable Nation

Agriculture,Industry,

Human Capital

Nutrition, Food Security and Sustainability

Agriculture,Imports

Food Industry

Food Secure Nation

Food Loss

Food Waste

STABILITY

Well Fed Nation

Healthy Nation

Productive, Resilient, Sustainable Nation

Accessibility

Availability

Utilization

Household

Individual

National

TransportPhysical

Economic

Food Quality,Safety,

Sanitation &Health

SustainableDiets

SUSTAINABILITYEnvironment, Economy, Culture GENERATIONS

Availability

SUSTAINABILITYFOOD SECURITY

Socio-Cultural

Economy

Environment

Accessibility

Utilization

STABILITY

Natural Resources&

Climate

Person-Centered Global

after Berry et al. Public Health Nutrition, 2015

Sustainable Diets position Sustainability in the Food Security Pathway

SustainableDiets

SHORT

TERM

LONG

TERM

Positive Deviance and the Mediterranean Diet and Sustainability

Elliot M [email protected]

2

Poor People spend more proportionately on Food. This means less for health and education – thus increasing vulnerability

% of total household spending

Spen

din

g per p

erson

per w

eek on

foo

d $

Economist, 2013

Food insecurity , malnutrition andpoverty are deeply interrelated

UN Sustainable Development Goals 2015How many involved with Food Security?? Sustainable Development Goals 1 (adapted from FAO)

1. No Poverty – c80% of poor people live in rural areas

2. Zero Hunger – Enough food for all, but c800 million go hungry…

3. Good Health & Well-being – Good Health starts with Nutrition ( -9 months)

4. Quality Education – Nutritious food is critical for Learning

5. Gender Equality – Women produce ½ world’s food, but lack access to land

6. Clean Water & Sanitation – Sustainable agriculture and re-cycling addresses water scarcity

7. Affordable & Clean Energy – Modern food systems rely heavily on fossil fuels

8. Decent Work & Economic Growth – Agricultural growth in low-income economies can reduce poverty by half

9. Industry, Innovation & Infrastructure – Agriculture accounts for 25% of GDP in Developing Countries

Positive Deviance and the Mediterranean Diet and Sustainability

Elliot M [email protected]

3

Sustainable Development Goals 2

10. Reduced Inequalities – Land reforms can give fairer access to rural land

11. Sustainable Cities and Commodities – Rural investment can deter unmanageable urbanization – 2/3 world population

12. Responsible Consumption & Production – 1/3 the food produced is lost or wasted

13. Climate Action – Agriculture is key to responding to climate change

14. Life below Water – Fish give 3bn people 20% of daily animal protein

15. Life on Land – Forests contain >80% of terrestrial biodiversity

16. Peace, Justice & Strong Institutions – Ending hunger can contribute to greater stability and peace

17. Partnerships for the Goals – To raise the voices of the hungry

ENVIRONMENTRegional

AVAILABILITYNational

ACCESSIBILITYHousehold

UTILIZATIONIndividual

STABILITY

SUSTAINABLE FOOD (SECURE) SYSTEMS & SD GOALS

Multi-Stakeholders: Government, Local Authorities, Farmers, Industry, NGOs,Academia, Civil Society … Consumers

THE CHALLENGE:How to MEASURE and MONITOR!!

Food Secure Vulnerability

Utilization

Stability

Individual

Household

National

“Short term”

Accessibility

Availability

Sustainable Food Systems and the SDG Goals

Waste

Loss

PhysicalEconomic

Aqua cultureAgricultural Production

Imports

Quality / SafetyQuantity

Health

SUSTAINABILITY GENERATIONS

“Long Term”

National Policyafter Berry et al, 2015, 2017

SDG 3Health &

Well-being SDG 6Clean water & Sanitation

SDG 12Responsible

Production & Consumption

SDG 15Life on Land

SDG 1No Poverty

SDG 14Life Below

Water

SDG 2Zero

Hunger

SDG 7Affordable & Clean Energy

SDG 13Climate Action

SDG 5Gender Equality

Example of a National Sustainable Food System : The “HOW”

1. Make Food System Sustainable along the entire food chain – from Production to Consumption; reduce food losses and waste

2. Strengthen Agriculture towards the best Sustainable practices

3. Protect the Right of All to healthful, nutritious & adequate food – Food Security

4. Monitor the safety of the food supply to be environmentally friendly and free of pathogens and pesticides

5. Legislate the Food Industry to produce minimally processed foods, with less added sugars, salt and additives. Incentives to produce healthy foods. Production & Marketing must be honest and transparent. No junk food marketing to children

6. School and Community Education on healthy life styles, nutrition, cooking (Mediterranean diet pattern), and EXERCISE

7. Promote access of healthy foods in restaurants & public places

Eating is not a list of do’s and don’ts but rather a pleasurable, tasty experience. Traditional and cultural preferences in food choices should be respected.

FAO, CIHEAM Technical Workshop, 2017

Positive Deviance and the Mediterranean Diet and Sustainability

Elliot M [email protected]

4

Why the Mediterranean Diet???: the ONLY diet with scientific evidence for health benefits

• Decreased Overall Mortality (-9%)

• Decreased Cardiovascular Mortality (-9%)

• Decreased Incidence & Mortality Cancer (-6%)

• Decreased incidence Parkinson’s disease (-13%)

• Decreased Incidence Alzheimer's disease (-13%)

Sofi F, Cesari F, Abbate R, Gensini GF, Casini A. Adherence to Mediterranean diet and health status: meta-analysis. BMJ. 2008; 337:a1344

Bach-Faig A, Berry EM, Lairon D et al. Mediterranean Diet Pyramid Today. Science and Cultural Updates. Public Health Nutrition. 14 (12A): 2274-2284, 2011 Berry et al. Mediterranean diet pyramid today. Science and cultural updates. Public Health Nutrition 2011; 14: 2274-84.

Every Main Meal

Every Week

CulturalElements

MODERATION

Every Day

BiodiversitySeasonalityTraditional

Eco-FriendlyProducts

EVERY MAIN MEAL contains basic elements:

Cereals: 1-2s, preferably whole grain (processing removes fiber

and nutrients such as Mg, Fe, vitamins).

Vegetables: ≥2s, at least 1 serving consumed raw.

Fruit: 1-2s, as dessert.

Olive oil: central, principal source of lipids.

Emphasis on variety in colors & textures.

The pyramid “core” – plant-origin foods – for prevention of many chronic diseases and for weight control.

Berry et al. Mediterranean diet pyramid today. Science and cultural updates. Public Health Nutrition 2011; 14: 2274-84.

Food Pyramid vs Environment Pyramid

Barilla CFN

Positive Deviance and the Mediterranean Diet and Sustainability

Elliot M [email protected]

5

Food Loss & Waste by Region

LOSS

WASTE

HIGHER IMPACT

• Healthy Diet, Healthy Caloric Intake, BUT

• Moderate Meat

• High in Dairy

• High in Fruit and Vegetables grown in GREEN HOUSE or AIR FREIGHTED

• High in Fruit and Vegetables grown in water stressed regions

LOWER IMPACT

• Healthy Diet, Healthy Caloric Intake,AND

• Low Meat

• Moderate Dairy

• High in Legumes and Pulses

• High in SEASONAL Fruit and Vegetables

Same Changes in Eating Patterns may have variable Environmental Impacts

Homo sapiens

Who-ever you are

Where-ever you live

What-ever you eat

The main storage fatty acid in

the human body

is

OLEIC ACID

Olive Oil, Almonds, Avocado

Berry, 1997

Oleic Acid is the link between the Socio-Biology and Culture of the

Mediterranean Diet

Mediterranean DietAVAILABLE

Mediterranean FoodEATEN

“Bottle Neck”ECONOMIC

SOCIO-CULTURAL

ChallengesToo Many Food Choices

Food PricesNO Time For Cooking

Women's Roles…EDUCATION

Positive Deviance and the Mediterranean Diet and Sustainability

Elliot M [email protected]

6

These 10 Corporations Control Almost Everything We Buy

Industrial Corporations prioritise PROFIT, not public health

Select the Mediterranean country with the least

Obesity (in women >15 yrs) = FRANCE

Select the Mediterranean country with the

highest Global Nutrition Index = FRANCE (#2)

Determine the Diet & Lifestyle

Discover the Population Behavior

Design & Do CULTURALLY APPROPRIATE

interventions… BUT not so SIMPLE….

Situation is Dynamic, especially with problem of

Childhood Obesity… where HOLLAND is “best”…

Q: How could we apply PD to improving

Compliance to the Mediterranean Diet…???

Challenges for Adherence to MeDiet

1. Standardized Methodology for assessment (Sofi et al., 2013; Milà-Villarroelet al., 2011).

2. Cooking Skills transmission of culinary and traditional eating habits necessary to achieve a sustainable MEDIET : an indicator for example number of "traditional dishes" prepared/week?

3. Time constraints prevent spending too much on preparation & cooking meals. Working Women…

4. Demographic transition – family structure has downsized, less youngsters and more elderly

5. Economic changes from 1960s…Not all foods from the MEDIET pyramid are affordable

Possible Solutions to Improve Adherence to MEDIET

Updating the MEDIET and LIFESTYLE (MEDAL) to stimulate interest of the young in it as a contemporary, accessible, “fashionable” and sustainable healthy lifestyle. ROLE MODELS

More Education in schools, in nutrition, cooking skills and exercise, with easy, quick meal choices within the MEDIET

Social networking & web-based communication and information

Bringing more market produce into supermarkets –health aisles…

Effective labelling for consumers of principal foods groups of the MEDIET

Positive Deviance and the Mediterranean Diet and Sustainability

Elliot M [email protected]

7

Promoting the Mediterranean Diet

Lifestyle:Interventions in Kindergartens &Junior Schools

Ronit Jakobovich, Asia Levita & Elliot M Berry in preparation, 2015

Maha Nubani PhD 2015. M Donchin, Ziad Abdeen & E M Berry

Changing Behaviours in EARLY CHILDHOOD – relevance for preventing Obesity and promoting the Mediterranean lifestyle

1890 Kindergarten CHILDREN aged 4-6 years

74 KINDERGARTEN TEACHERS

52 hour training Program

Intervention group: 1048 Children

42 Kindergarten teachers

Control group: 842 Children32 Kindergarten teachers

Evaluation after 9 months Intervention

Changes in Eating Habits

44

26

59

41

34

27

35

26

0

10

20

30

40

50

60

70

FRUITS VEGS

Pre Int Post Int

N Intervention 1048Control 842

19

39

7

74

18

47

19

45

0

10

20

30

40

50

60

70

80

SWEETS WATER

PRE INT POST INT

If a child can say to himself /herself:

“If I eat healthy food and do my physical exercises, then I’ll stay healthy”

Then, we have achieved our goal…

Conclusion:

It is possible to change behaviours towards a Mediterranean Lifestyle –

even in Kindergartens

Positive Deviance and the Mediterranean Diet and Sustainability

Elliot M [email protected]

8

An Intervention Program for Promoting Healthy Eating & Physical Activity among Palestinian Girls in Grades 4 & 5

Needs Assessment in 7 Intervention & 7 Control Schools

897 Pupils,

373 Teachers &

744 Mothers 2 Interventions of 10 months

Maha Nubani PhD 2015. M Donchin, Ziad Abdeen & E M Berry

Changes in Behavior: Nutrition and Activity

38.5

29.8

53.1 54.7

34.6

25.5

31.7

21

0

10

20

30

40

50

60

BREAKFAST F & V

PRE INT POST INT

16.5

34.7

61.2

28.9

13.6

31.9

13.1

30

0

10

20

30

40

50

60

70

PA TV

PRE INT POST INT

S

At 2 years follow-up, the programme is still running in 6 / 7 of the intervention schools, is being implemented in 5 / 7 of the control schools.

Additionally, several other schools are requesting to start the programme too…

SUSTAINABILITYof

PROJECT

Osnat KeidarFrom PhD Dissertation 2011

Health Promoting Schools - Improving Health & Hygiene in the Korogocho Slums of Nairobi, Kenya

They said it could not be done……

Positive Deviance and the Mediterranean Diet and Sustainability

Elliot M [email protected]

9

ToiletsBefore

After

Before After

Student BMI improved just through hand washing!!

*

*p<0.001

Education is THE number 1 Priority

Positive Deviance and the Mediterranean Diet and Sustainability

Elliot M [email protected]

10

Albert Einstein: "I fear the day when technology will outpace humanity. Then, the world will have a generation of idiots."

The curse of mobile phones…..

BUT…they are the future for Food Security!!! Survey Data, Health care and Farmer’s markets and more…

Berry’s ”E - Messages” for Public Health Nutrition by Sociotype

Individual / Health• EATING for ENJOYMENT • EXERCISERelationships• EMPOWERMENT• EQUITY, EQUALITYContext• EDUCATION• EMPLOYMENT• ECONOMICS• ENVIRONMENTAL ENGINEERING

David Ben GurionYotvata 1957

תצליחותתמידו תעיזו

Dare, Persist, Succeed

DO’s Fruits & vegetables –

5 portions daily –”colories”

“Biblico-Mediterranean” diet - Olive Oil

Sea Fish – twice a week

Spouse support & socialize (Family meals ENJOY!!)

Exercise –“Every step counts”

Practical Advice: 10 Lifestyle “Commandments”

DON’Ts

Smoke

Eat so much

Add salt (other spices OK)

Alcohol < 20-30 gm /day

Speed when driving

“Obesity is the price you pay for exceeding the feed limit…” - anonymous

“Is it on a disk?”

Positive Deviance and the Mediterranean Diet and Sustainability

Elliot M [email protected]

11

FOOD SECURITY (Public Health): Food should be AVAILABLE & ACCESSIBLE & ADEQUATE & ENJOYABLE

for ALL: MEDITERRANEAN LIFESTYLE

Four Final Thoughts:“Tell me your SOCIOTYPE” &

I will tell you How you COPE...

NUTRITION:“MODERATION in all things, including MODERATION”

(David Berry z”l)

SOCIOTYPE:...It is more important what comes OUT

of your mouth than what goes IN….. (Matthew 15.11)

COPING: (3-fold cord) How you cope is the life-long interaction between your

Genotype Phenotype [email protected]

Exercising at a RED Light

1 Hand squeeze

2 Isometric hand press

3 Stomach into Spine

4 Pelvic Floor - O Ring

CONCLUSIONS:FOOD SECURITY & INSECURITY

63

Life is in your hands….

“ Be the Change you wish to bring about”

M.K. Gandhi

Be a POSITIVE DEVIANT….

Positive Deviance and the Mediterranean Diet and Sustainability

Elliot M [email protected]

12

My Hero!“My inspiration are men and women whohave emerged throughout the globe, and whohave chosen the world as the theatre of theiroperations and who fight socio-economicconditions….who fight the suppression of thehuman voice, who fight disease, illiteracy,ignorance, poverty and hunger. Some areknown, others are not…”

Speech LSE, UK, 6th April 2000

Truth & Reconciliation Commission“The need for Understanding, but not for VengeanceA need for Reparation, but not Retaliation,A need for UBUNTU, but not for Victimization…”

Umuntu ngumuntu ngabantu

“What we need today, for the sake of survival of this planet, is long-term vision. Can governments whose very survival depends on immediate, extractive, short-term gain provide this?.....Our inability to live entirely in the present (like most animals do) combined with our inability to see very far into the future makes us strange in-between creatures, neither beast nor prophet. …We plunder the earth hoping that accumulating material surplus will make up for the profound, unfathomable thing that we have lost.”

Sustainability requires Vision AND Political Will …

Political Will + People’s Will = Sustainable Will

Isatou Jallow, Las Palmas, 2014

Born in The Gambia, former Chief of Women, Children & Gender Policy for the UN World Food Programme (WFP)

a major advocate for Gender Equality and the Empowerment of Women.

CONCLUSIONS:FOOD SECURITY

&INSECURITY

&SUSTAINABILITY

&SOCIOTYPE

=PUBLIC HEALTH NUTRITIONand be POSITIVE DEVIANTS

[email protected]

Food Security & Public Health Nutrition

A Well-Fed Nation

is a

Healthy Nation

is a

Productive Nation

[email protected]

Positive Deviance and the Mediterranean Diet and Sustainability

Elliot M [email protected]

13

Supplementary Reading List

1.Kafka: The Hunger Artist

2.Knut Hamsun: Hunger

3.Damon Runyon: A Little Piece of Pie

INDIVIDUAL / HEALTH:“Tell me what YOU eat and

I will tell you what YOU are”RELATIONSHIPS:“Tell me how a FAMILY eats and

I will tell you how it FUNCTIONS”

CONTEXT:“Tell me how a NATION eats and

I will tell you its VALUES”Do kids go to bed hungry??

= COPING with FOOD INSECURITY & SOCIAL JUSTICE& SUSTAINABILITY

The Sociotype & Coping with Food Insecurity

FOOD

CULTURE

↓↓

Jean Brillat-Savarin, 1825,

La Physiologie du Gout

“Tell me what YOU eat &

I will tell you who YOU are”

“Tell me how a FAMILY eats & I will

tell you how it

FUNCTIONS”

“Tell me how a NATION eats &

I will tell you its VALUES”

SOCIOTYPE▼

Individual Health

Relationships

Context

Production: Where?

Washing-UpWaste, Re-Use,Activity

4. Post Meal:

3. THE MEAL: Which?, When?Where?, With whom?Quantity?, Duration?

1. Purchase: Where? How? What?How Often?

2. Preparation: Menu Planning, By Whom?, How?

The ANATOMY of a MEAL

Positive Deviance and the Mediterranean Diet and Sustainability

Elliot M [email protected]

14

Food Choices AestheticsSetting

TasteSmell

Price

Physiology: Hunger, Blood Sugar, Insulin

HabitsExperience

Determinants of Food Choices Food Culture: The Culinary Triangle: (Lévi Strauss & Leach)

Raw

RottenCooked

NatureCulture

Transformed

Normal

State of

Material

• Sushi (Raw),

• Smoked Salmon (Smoked),

• Chicken soup (Boiled),

• Mutton (Roast),

• Souffle (Cooked),

• Stilton / Gorgonzola Cheese (Rotten)

Air

SmokedWater

Boiled

Mediterranean Diet????

It is culturally unacceptable to lose

weight in Kumasi, Ghana….

… and other culture icons..

Pets of obese people are fatter than pets of lean

people….


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