Caroline’s Vision 20 years later

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.

First AnniversaryJonathan

Aitken

Jonathan Porritt

Caroline Walker Trust: policy publications: eating

well throughout life

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

Nairobi, Kenya

Dhaka, BangladeshDakar, Bangladesh

Nairobi, Kenya

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

Valentano, Lago di Mezzano, Italy.

North of England.

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