Tackling chronic diseases: an international perspective Philip James IPA IDF IOTF IUNS WHF LSHTM and...
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Tackling chronic diseases:Tackling chronic diseases:an international perspectivean international perspective
Philip JamesPhilip James
IPAIDFIOTF
IUNS WHF
LSHTM and Chair of IOTF and thePresidential Council of the Global Prevention Alliance
Deaths from Deaths from chronic disease chronic disease
20052005
Abegunde et al, Burden & costs of chronic diseases in
low income and middle income countries Lancet, Dec.2007.
% Dietary energy from saturated fatty acids
10-y
r. C
oro
nar
y d
eath
s p
er 1
0,00
0 m
en
0 5 10 15 20 250
200
400
600R = 0.84
Corfu
S. Italian
Crete
S. Italian
JapanYugoslavia
10-year coronary mortality in men
0
100
200
300
400
500
600
0
100
200
300
400
500
600
132
300 309
499
578
125101 87
178
227
CHD death rates per 100,000
Northern Europe Southern Europe
Never smokedStopped smoking<10 cigarettes/day10-19 cigarettes/day>20 cigarettes/day
0
100
200
300
400
500
600
0
100
200
300
400
500
600
132
300 309
499
578
125101 87
178
227
CHD death rates per 100,000
Northern Europe Southern Europe
Never smokedStopped smoking<10 cigarettes/day10-19 cigarettes/day>20 cigarettes/day
The importance of diet (saturated fat intakes) in amplifying smoking's cardiovascular effects
The importance of diet (saturated fat intakes) in amplifying smoking's cardiovascular effects
From: Keys A. (Ed). Seven countries. A multivariate analysis of death and coronary heart disease. Cambridge, MA, US: Harvard University Press, 1980.
Risk factors in global cardiovascular disease; identifiable criteria usable Risk factors in global cardiovascular disease; identifiable criteria usable
in cancer studies but other risk factors demand special testsin cancer studies but other risk factors demand special tests Modifiable risk factors for myocardial infarction: PAR% Modifiable risk factors for myocardial infarction: PAR%
ApoB/ApoA1 ratio( top vs lowest quintile): 49.2ApoB/ApoA1 ratio( top vs lowest quintile): 49.2
Smoking (current & former vs never): 35.7Smoking (current & former vs never): 35.7
Psychosocial factors: 32.5Psychosocial factors: 32.5
Abdominal obesity(top vs bottom tertile): 20.1Abdominal obesity(top vs bottom tertile): 20.1
Hypertensive history: 17.9Hypertensive history: 17.9
No daily fruit and vegetable intake: 13.7No daily fruit and vegetable intake: 13.7
Regular physical activity: 12.2Regular physical activity: 12.2
Diabetes: 9.9Diabetes: 9.9
Regular alcohol intake:Regular alcohol intake: 6.7 6.7
Total impact of all 9 factors: men 90%Total impact of all 9 factors: men 90%
women 94%women 94%Yusuf et al. INTERHEART study Lancet Sept.11th 2004,364:937-952.
The importance of modest weight gain in precipitating The importance of modest weight gain in precipitating chronic disease: risks markedly increase within chronic disease: risks markedly increase within
"normal" BMI range"normal" BMI range
Adapted from Willett, Dietz & Colditz, NEJM, 1999; 341, 426-434
Body Mass Index
Re
lati
ve
Ris
k
Women
1
2
3
4
5
6
0<21 22 23 24 25 26 27 28 29 30
Type 2 diabetes
Coronary Heart Disease
Hypertension
Aged 30-55 at start
"Normal" BMIs
Escalating obesity rates in adultsEscalating obesity rates in adults
IOTF 2007
0
5
10
15
20
25
30
35
1970 1975 1980 1985 1990 1995 2000 2005
Year
% O
bes
e (B
MI =
>30
kg
/m2) England
Finland
Norway (Tromsø)
Sweden (Goteborg)
Australia
Japan
Brazil
Cuba
USA
35
30
25
20
15
10
5
0
1970 1975 1980 1985 1990 1995 2000 2005
YEAR
USA
Finland
England
Australia
Japan
Cuba
Sweden(Goteborg)
Brazil Norway (Tromsø)
% Obese (BMI >30 kg/m2)% Obese (BMI >30 kg/m2)
20022002Obese: 356 millionO/wt >25: 1.4 billion
2007 Obese: 523 millionO/wt ≥25: 1.539 billion
20152015Obese: 704 millionO/wt >25 : 2.3 billion
20022002Obese: 356 millionO/wt >25: 1.4 billion
2007 Obese: 523 millionO/wt ≥25: 1.539 billion
20152015Obese: 704 millionO/wt >25 : 2.3 billion
Global TotalsGlobal Totals
0%
5%
10%
15%
20%
25%
30%
35%
16 18 20 22 24 26 28 30 32 34 36 38 40
Asian Male
Caucasian Male
Asian Female
Caucasian Female
BMI (kg/m2)
Huxley R, James WPT et al. Obesity in Asia Collaboration. Ob. Rev. (in press 2007)
Asian Males
Asian Females
CaucasianMales
CaucasianFemales
Diabetes
A comparison of the impact of BMI on A comparison of the impact of BMI on Diabetes in Asians and Caucasians Diabetes in Asians and Caucasians
35
30
25
20
15
10
5
0
16
5
20 24 28 32 36 40
BMI
%
WHOAsian limit
O/W Obese
0
5
10
15
20
25
30
35
40
% p
reva
len
ce
2003
2025
2003
2025
2003
2025
2003
2025
2003
2025
2003
2025
2003
2025
2003
2025
2003
2025
2003
2025
Diabetes IGT
Vietnam
The predicted escalation of the burden from diabetes and IGTThe predicted escalation of the burden from diabetes and IGT
Diabetes Atlas, IDF, 2003.
ChinaTaiwan
Philippines
Thailand
Australia
Korea
Hong Kong
Malaysia
Singapore
The environmental impact in Asia on the population'sThe environmental impact in Asia on the population's health burden from diabetes and IGThealth burden from diabetes and IGT
Source: Diabetes Atlas, 2Source: Diabetes Atlas, 2ndnd edition. IDF, 2003. edition. IDF, 2003.
4
Diabetes is prevalent in developing anddeveloped countries
http://www.idf.org (Accessed February 2003)
0
10
20
30
40
Population affected (millions) - Year 2000
32.7
22.6
15.3
8.87.1
India China USA Pakistan Japan
Diabetes is prevalent in developing and developed countriesDiabetes is prevalent in developing and developed countries
The top global prevalences for adult type II The top global prevalences for adult type II diabetes 20-79 year age group 2003diabetes 20-79 year age group 2003
NauruNauruUAEUAEBahrainBahrainKuwaitKuwaitTongaTongaSingaporeSingaporeOmanOmanMauritiusMauritiusGermanyGermany
SpainSpain
PREVALENCE %PREVALENCE %
0 5 10 15 20 25 30 35
Source: Diabetes Atlas, 2Source: Diabetes Atlas, 2ndnd edition. IDF, 2003. edition. IDF, 2003.
02468
101214161820
21-22 23-24 25-26 27-28 29-30 >30
02468
101214161820
21-22 23-24 25-26 27-28 29-30 >30
Body mass index NHANES NHS 2000
02468
101214161820
70-74 75-79 80-84 85-89 90-94 95-99 100-104 105+02468
101214161820
70-74 75-79 80-84 85-89 90-94 95-99 100-104 105+
**
** *
**
*
**
** * *
**
*
Waist Circumference (cm) NHANES NHS 2000
Per
cen
tag
e
MenWomen
Sánchez-Castillo et al, Public Health Nutr. 2005;8:53-60Sánchez-Castillo et al, Public Health Nutr. 2005;8:53-60
Prevalence of type 2 diabetes in Mexican and US Prevalence of type 2 diabetes in Mexican and US population (Non-Hispanic whites) standardized by agepopulation (Non-Hispanic whites) standardized by age
A Comparison of the impact of BMI on A Comparison of the impact of BMI on Hypertension in Asians and CaucasiansHypertension in Asians and Caucasians
Hypertension
Huxley R, James WPT et al. Obesity in Asia Collaboration. Ob. Rev. (in press 2007)
Asian Males
Asian Females
Caucasian Females
Caucasian Males
16 20 24 28 32 36 40
BMI
100
80
60
40
20
0
%
WHOAsian limit
O/W Obese
% Dietary energy from saturated fatty acids
10-y
r. C
oro
nar
y d
eath
s p
er 1
0,00
0 m
en
0 5 10 15 20 250
200
400
600R = 0.84
Corfu
S. Italian
Crete
S. Italian
JapanYugoslavia
10-year coronary mortality in men - Seven Country Study
The striking contrast The striking contrast in global nutritional in global nutritional problemsproblems
Yajnik and Yudkin, Lancet, 2004, 363:163.
The Y-Y ParadoxThe Y-Y Paradox
Fetal origins of non-insulin-dependent diabetes and insulin Fetal origins of non-insulin-dependent diabetes and insulin resistance syndrome: the 'thrifty phenotype' hypothesis.resistance syndrome: the 'thrifty phenotype' hypothesis.
Maternal malnutritionMaternal malnutrition
HyperlipidaemiaHyperlipidaemiaNon-insulin
dependent diabetesNon-insulin
dependent diabetesHypertensionHypertension
Insulin resistance syndrome
Insulin resistance syndrome
Fetal malnutritionFetal malnutrition
Adapted from Barker, D. Mothers, Babies & Health
Other organ malfunction
e.g. liver
Decreased ß cell mass
Insulin resistance
Abnormal vascular
development
Other maternal or placental abnormalities
ObesityAge
Epigenetic suppression by promoter methylation and structural chromatin changes
Vitamins, minerals, aminoacids, EFAs etc.
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 WeaningFrequent
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
Adult chronic Adult chronic diseasesdiseases
Adapted from James et al. SCN Millennium Rep. Food & Nutrition Bulletin, 2000, 21, 3S.
NOTE: On average 18% of babies born in the developing world are of low birth weight.
L. A
mer
ica
- C
arib
bean
Mid
dle
Eas
t - N
. A
fric
a
Sub
-Sah
aran
A
fric
a
Eas
t A
sia
/ P
acifi
c
Sou
th A
sia
0
10
20
30
40
50
% babies born with weights
<2.5 kg
The Developing World
Source: UNICEF, 1997.
Ban
glad
esh
Indi
a
Pak
ista
n
Sri
Lan
ka
Mal
dive
s
0
10
20
30
40
50
South Asia
% babies born with weights
<2.5 kg
MethionineTHF DHF dUMP
dTMP
SAM
DMG
DNA
DNA METHYLATION
DNA METHYLATION
HOMOCYSTEINE
DNA SYNTHESIS & REPAIR
DNA SYNTHESIS & REPAIR
BHMTMS
SHM
TS
MTHFR
FADFormyl THF
PURINES5-MeTHF
5,10-MeTHF
Folic acid
BETAINE
CHOLINE
RIBO-FLAVIN
B12
B6
Vitamin / nutrient involvement in DNA imprinting and cellular synthesis Vitamin / nutrient involvement in DNA imprinting and cellular synthesis
Kimura et al. MTHFR, Folic Acid, Riboflavin and genome stability. 2004 J. Nutr., 48-56. American Society for Nutritional Sciences.
Lifecycle: the proposed causal links
Early onset Type 2
Diabetes
Reduced play and
social isolation
Reduced capacity to
care for baby
Disordered foetal
nutrition
Higher mortality
rate Impaired mental development later
Untimely / inadequate Early
WeaningFrequent fast foods
Inadequate physical activity
Normal/high growth
WomanO/W - obese Pregnancy
Glucose intoleranceDiabetes Adolescent
O/W-obese
Child overweight
Elderly Diabetic,arthritic, Ob
BabyHigh Birth
Weight
Poor school conditions
Inadequate obstetric care
Reduced job opportunitie
s
Inadequate health care
system
Visceral obesity, H/T,
Diabetes
RapidRapid weight gainweight gain
Adult chronic Adult chronic diseasesdiseases
Adapted from James et al. SCN Millennium Rep. Food & Nutrition Bulletin, 2000, 21, 3S.
Reduced fertility;
CVD, HT Cancers
Projected overweight (incl. obesity) rates for Projected overweight (incl. obesity) rates for school age children school age children
Wang and Lobstein, IOTF, 2006.
e.g. China
e.g. India
%%
PrevalencePrevalence
e.g. US
S.Arabia
e.g. UK
Global totalGlobal totalObese 74 mil.Obese 74 mil.O/wt 287 mil.O/wt 287 mil.
Global totalGlobal totalObese 74 mil.Obese 74 mil.O/wt 287 mil.O/wt 287 mil.
The increasing risk of adult coronary heart The increasing risk of adult coronary heart disease as childhood BMIs increase by one Z disease as childhood BMIs increase by one Z
score from 7-13 yrsscore from 7-13 yrs
Copenhagen school children's study on 276,835 children measured from 1955 - 1960 with National Death and Hospital Discharge Registries . BMI Z scores linearly related to events at all ages but hazard ratio progressively increased with age as shown.
Baker, Olsen & Sorensen. NEJM 2007, 357: 2329-32
WHO global strategy on WHO global strategy on diet, physical activity and health diet, physical activity and health
• Agreed by 191 governments
• Recommendations to curb consumption of fat, sugar and salt
• Action programme to engage regions and countries in implementing effective strategies
The traditional Mediterranean diet 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
1500
Fish
Fruit
Vegetables
CerealsFats & oils
Milk
Meat
Eggs
Alcohol
Sugars etc.
Gra
ms
USA
Adapted from Bray & Popkin, Am. J. Clin. Nutr., 1998; 68: 1157-73 and data from FAO 2005, CFNI and national surveys
Dietary fat and overweight : Latin American Dietary fat and overweight : Latin American & Caribbean comparisons + sugar effect & Caribbean comparisons + sugar effect
The epidemic is inevitable unless policies to substantially reduce fat and sugar intakes and increase activity are introduced now
Per
cen
tag
e B
MI
Per
cen
tag
e B
MI >
> 25
.0 2
5.0
80
60
50
40
30
20
10
70
Dietary Fat (%) 20 25 30 35 40
Kuwait
Morocco
Philippines
MaliChina
India Congo
TunisiaMalaysia
Australia
New Caledonia
ItalyBrazil
Russia
Kyrgyzstan
Cuba
S. Africa
r = 0.88r = 0.88
Barbados
Guyana
Trinidad & Tobago
Jamaica
+ 20% sugar
Increased vegetable oil consumption is a key component of the shift in the stages of the Nutrition Transition in AsiaIncreased vegetable oil consumption is a key component of the shift in the stages of the Nutrition Transition in Asia
Source: Food Balance data, UNFAO
Current intakes in relation to ideal international goals
6
8
10
12
14
16
18
20
22
20
25
30
35
40
45
50
55
A = Austria; B = Belgium; FIN = Finland; GER = Germany; GR = Greece; IRL = Ireland; IT = Italy; NL = Netherlands; SP = Spain; SW = Sweden; UK = United Kingdom
% fat energy % SFA energy
Institute of European Food Studies (IEFS) Ireland. 2000
= range of member state recommendations for these nutrients
A
B
NLGER
FIN
GR
S
NL
IT
FINS
A
GR
GER
Current intakes (inter-quartile ranges) in European National surveys in relation to nutrient goals
Current intakes in relation to ideal international goals
A = Austria; B = Belgium; FIN = Finland; GER = Germany; GR = Greece; IRL = Ireland; IT = Italy; NL = Netherlands; SP = Spain; SW = Sweden; UK = United Kingdom
* females only
5
10
15
20
25
30
35
40
45
0
50
100
150
200
250
300
350
400
Fibre (g/day) Folic acid (g/day)
A
B
NL
GERFIN
IRL
GR
SP
SP
SW
IRLNL*
ITFIN UK
= range of member state recommendations for these nutrients
Institute of European Food Studies (IEFS) Ireland. 2000
Prentice AM & Jebb SA. Obesity Reviews, 2003, 4: 187-194
The energy density of different foods is markedly The energy density of different foods is markedly influenced by their fat contentinfluenced by their fat content
High energy dense foods (kcal / 100g) cost less (€ / 1000 kcal)High energy dense foods (kcal / 100g) cost less (€ / 1000 kcal)
Darmon, Darmon, Maillot and Drewnowski, JADA, 2005
A quarter-pound cheeseburger, A quarter-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 cholesterol 1,450 mg sodium1,450 mg sodium
The keys to success in the food The keys to success in the food business and in obesity and chronic business and in obesity and chronic
disease preventiondisease prevention
• PricePrice
• AvailabilityAvailability
• MarketingMarketing
'U.S. foreign direct investment in food 'U.S. foreign direct investment in food manufacturing $ million 2001-03 manufacturing $ million 2001-03
Source: FAO data and projections
World average meat consumption World average meat consumption per person, 1964-66 to 2030per person, 1964-66 to 2030
1964-66 1997-99 2030
Co
nsu
mp
tio
n (
kg/c
apit
a/ye
ar) Beef
Pig meat
Sheep & goat meat
Poultry
The fall in the cost of agricultural commodities The fall in the cost of agricultural commodities 1960-20001960-2000
Based on world market prices related to 1990
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.
US farm subsidies $ billionUS farm subsidies $ billion
0
5
10
15
20
25
1995 1997 1999 2001 2003
EU CAP ExpendituresEU CAP Expenditures
€43.5 bn
Source: Schäfer Elinder L., Public Health Aspects of EU CAP, 2003
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 restrictions
Nutritional 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 drinks
Social/employment/medical policies for breast feeding as the norm
Complementary Complementary approaches to approaches to obesity & obesity & chronic disease chronic disease preventionprevention
Complementary Complementary approaches to approaches to obesity & obesity & chronic disease chronic disease preventionprevention
Derek Wanless report to UK Prime Minister Derek Wanless report to UK Prime Minister 2004 & Kings Fund Sept 2007!2004 & Kings Fund Sept 2007!
• Major health problems and costs relate to:Smoking, Obesity (diet)Physical inactivity
• Causes are socio-economic • Solutions are socio-economic • The Dept of Health copes - cannot solve the problemsWednesday 11Wednesday 11thth Sept: Sept:
• "However, without ….efforts to tackle key determinants of ill health, such as obesity, even higher levels of funding will be needed over the next two decades to deliver the high-quality services envisaged by the 2002 Wanless review."
Wanless D. Reports to the Treasury on Public Health: First Report, 2002; Second Report, 2004
Wanless et al. Our future Health Secured? Sept 11th 2007
Who controls the food chain ? Who controls the food chain ?
Adapted from 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
Nutritionists advocate a "balanced diet": the emergence Nutritionists advocate a "balanced diet": the emergence of coronary heart disease in the Western worldof coronary heart disease in the Western world
UN Commission Report: Food & Nutrition Bulletin, 2000.
)
Changes in CHD Risk Factors in Finland Men & Women aged 30 - 59
1972 1976 1980 1984 1988 19925.2
5.6
6
6.4
6.8
7.2Cholesterol
1972 1976 1980 1984 1988 19928
16
24
32
40
48
56
Smoking
N. Karelia
S.W. Finland
Vartiainen et al., Int. J. Epid. 1994, 23: 495.
1972 1976 1980 1984 1988 199270
80
90
100
110
120
130
140
150
160Blood Pressure
Systolic
Diastolic
% smokers mmol/lmmHg
Year
Men
Women
Note remarkable 10mmHg fall in BP and 15% drop in cholesterol - not drug based
Comparing the observed male mortality rates from CHD in N.E. Finland with those predicted from changes in the risk factors.
Vartiainen et al. 1994.
1975 1980 1985 1990-70
-60
-50
-40
-30
-20
-10
0
Observed mortality
Smoking
Blood pressure
All three risks
Cholesterol
Per
cen
t d
ecli
ne
Mortality now down by 90%
CHANGING DIETARY PATTERNS IN SCANDINAVIA 1965 - 1990
Vegetables (kg/hd/wk)
Fat (kg/hd/wk)
0
0.2
0.4
0.6
0.8
1970 1980 1990
Denmark
Finland
0
0.4
0.8
1.2
1970 1980 1990
Denmark
Finland
Fish (kg/hd/wk)
0
0.2
0.4
0.6
1970 1980 1990
Denmark
Finland
Milk (l/hd/wk)
0
1
2
3
4
5
1970 1980 1990
Denmark
Finland
Nat. Public Health Inst., Helsinki, Finland.
The biggest change in diet ever seen other than in war and famine
Cost to implement interventions US$ per Cost to implement interventions US$ per person per year 2005person per year 2005
Azaria et al Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet chronic
disease series Dec 2007
Altering sales tax but preserving Altering sales tax but preserving revenue in Denmarkrevenue in Denmark
• Reduce vegetable, fruit, wholegrain Reduce vegetable, fruit, wholegrain tax: 25% tax: 25% 22% 22%
• Increase tax on butter, cheese, beef, Increase tax on butter, cheese, beef, pork, fatty meats: 25% pork, fatty meats: 25% 31%31%
• Add sugar taxAdd sugar tax
NB:NB: income to government unchangedincome to government unchanged
Smed S & Denver S. Food & Resource Economics Ints. KVL Univ., Denmark, April 2005.
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.
Illustration of the GDA systemIllustration of the GDA system
GDA labelling shows percentages of guideline daily amounts per serving
Conceptually flawed - major differences between individuals' energy needs. Method failed in US - despite %RDA labelling diet terrible and obesity escalating
The most cost-effective community (not national) The most cost-effective community (not national) interventions in Australiainterventions in Australia
Victoria State Analyses: Sept 2006
Intervention Cost in Australian $ for each DALY saved
Restrict TV advertising 4
Soft drink intervention at school 3,000
Walking buses to school 770,000
Cycling (travel SMART schools) 260,000
After-school community programmes. 90,000
Doctors targeting the overweight children 32,000
School multiple interventions, but no physical education 14,000
AddAdd Physical Education 7,000
School education to reduce TV viewing 3,000
Family-based program for obese child 4,000
School program targeting overweight & obese children 3,000
Medical treatment with drugs, e.g. Orlistat 14,000
COMMUNITYLOCALITY
Agriculture/Gardens/
Local markets
Health Care
PublicSafety
PublicTransport
Manufactured/Imported
Food
Sanitation
Modified from Ritenbaugh C, Kumanyika S, Morabia A, Jeffery R, Antipatis V. IOTF website 1999: http://www.iotf.org
POPULATION
%
OBESE
AND
OVER-WEIGHT
WORK/SCHOOL/HOME
SchoolFood &Activity
Infections
Labour
Worksite Food & Activity
LeisureActivity/Facilities
Family &Home
INDIVIDUAL
EnergyExpenditure
Food intake :
Nutrient density
Societal policies and processes influencing the population prevalence of obesity
NATIONAL/ REGIONAL
Education
Food & Nutrition
Urbanization
Health
Social security
Transport
Media &Culture
Nationalperspective
INTERNATIONALFACTORS
Development
Globalizationof
markets
Media programs
& advertising
The Foresight causal map of obesityThe Foresight causal map of obesity
Indiv Phys Activ..
Physical Activity Envir.
Individual Psychology
Food Production Intake
PhysiologyPhysiology
Societal PsychologySocietal Psychology
WHO
Health statisticsDietary & risk fact.surveys
Nutritional surveillanceFood production
AgriculturalFood production statistics
Market structureImport/export policies
Food security measuresPublic perception
Economic evaluation of policy proposals
National Information
FAO, UNICEF, UNESCO, WTO, World Bank etc.
MINISTRY of HEALTH(HEALTH POLICY
GROUP)
INDEPENDENT NATIONAL
INSTITUTION
Nongovernmental organizations and
consumer representatives
Ministry of health actions1. Professional training2. Health promotion
national networks (NGO, voluntary Orgs.)
national campaign3. Regional and district food policy4. Catering establishments5. Priorities, research and surveillance
Actions
Ministry of Education
Ministry of Information
Ministry of Agriculture/Environment
Ministry of Trade
Ministry of Finance
Ministry of Foreign Affairs
• school & postgraduate education• school meals
• coordinating educational materials
• re-evaluation of current policies
• controls on food industry
• licensing, cooperative trade arrangements
• tax, subsidy adjustments
• policy on import / export trade
• coordinating regional actions
Private sector
Formulating a nutrition policy for the prevention of obesity and chronic disease
The interest and influences of different stakeholdersThe interest and influences of different stakeholders
INFLUENCEINFLUENCE
-10
-5
0
5
10
INT
ER
ES
TIN
TE
RE
ST
Children
Health professionals
Advocacy orgs.
Scientists
ParentsMinistry of Health
Parliament
Farmers
Media
Church
Ministries of Transport
& Agriculture
Retailers
Treasury
President
Advertising industry
Food/drink industry
Food inspectors
Ministry of Education
Teachers
0 5 10
Ministry of Trade
Lobstein T : Analyses based on The Food Commission's experience and new EU policy work.
• European Charter on Counteracting Obesity signed by 48 Ministers of Health
• Policy tools range from legislation to public/private partnerships, with particular importance attached to regulatory measures.
• International approaches emphasised with e.g. the development of a Code of Marketing of HFSS products particularly to children – to go forward into the second Food and Nutrition Action Plan (FNAP) for Europe
European Ministers' Istanbul Charter European Ministers' Istanbul Charter Nov 17, 2006Nov 17, 2006
Ministry of Health – direct responsibilities
Dietary quality;physical activity
Food safety Environment
Physical Appropriately accessiblehealth centres.Promoting access toappropriate self-monitoring,e.g. weight, BP
Catering in hospitals;monitoring facilities;
Fluoridation systems forwaterFacilities for iodising salt
Economic Primary health payments forspecific targets inmanagement
Penalties forproviding unsafe food
?? subsidise iodine foriodination purposes
Policy Baby Friendly HospitalsDietary guidelinesestablishing fortificationpoliciesEstablish policies on healthclaims, e.g. functional foods
Health impact ofmulti-sectoral foodsafety policies
Establish specificguidelines for toxicantsand contaminants in soil,water and primary foodproductsHIA of agrochemical use
Socio-cultural
Health education Promote concept oflimited clinicalantibiotic use
Promote new concept ofhealth impact of newtraffic policy;
Source: WHO Euro Nutrition Action Plan. Inspired by the ANGELO model, Egger and Swinburn, BMJ 1997, 315, 477-480
The STEFANI model: strategies for effective nutritional initiativesThe STEFANI model: strategies for effective nutritional initiatives
Other ministries: specified on a national basis
Dietary quality;physical activity
Food safety Environment
Physical Ensuring playgrounds in schools,suitable cycling and road systems;urban planning; sports facilities.Designated urban areas for localfood production
Provision of appropriate localabattoirs. Proper public toilet andsanitary facilities. Proper cateringfacilities based on stringent hygienerequirements
Urban planning: green spaces, cyclepaths, parks, playgrounds, lead free
Establish facilities for farmers markets
Economic Re-evaluate taxation and subsidypolicies
Establish appropriate penalties forinappropriate hygiene
Reform CAP. Finance new publictransport systems. Promote urbanagriculture, new outlets for highquality, affordable foods in deprivedareas
Policy HIA of CAP
Food labelling with appropriate,understandable health relatedinformation;
Establish criteria for ensuringpathogen and contaminant-freeaccess to the food chain. Establishsystematic HACCP for food chain,systematic surveillance andmechanisms for emergencyresponse
Reform CAP
Develop soil improvement, cleanwater, agricultural recycling, planting,fertilizer, pesticide, water use policies;
Socio-cultural
Promote physical activity in theworkplace. Create breastfeedingtime and space in the workplacewith NGO help
Establish new criteria for excludingantibiotics as growth promoters andspecifying veterinary use
Educational initiatives for safety offast food outlets, and modifyingnutrient composition, and limitingand ensuring appropriate foodwaste disposal
Change attitudes to cycle path use,pedestrian areas. Educationalinitiatives for caterers, communal useof school recreational facilities
Source: inspired by the ANGELO model, Egger and Swinburn
The STEFANI model: strategies for effective nutritional initiativesThe STEFANI model: strategies for effective nutritional initiatives
Source: inspired by the ANGELO model, Egger and Swinburn, BMJ 1997, 315, 477-480
Trinidad summit of Prime Ministers Trinidad summit of Prime Ministers September 15September 15thth -17 -17thth 2007 2007
1.1. Collaboration Collaboration between CARICOM, PAHO, WHO between CARICOM, PAHO, WHO &partners!&partners!
2.2. Establish National CommissionsEstablish National Commissions3.3. Legislation: immediate implementation tobacco Legislation: immediate implementation tobacco
framework: framework: ban sale marketing etc to children, tax, limitban sale marketing etc to children, tax, limit4.4. Money: Money: from tobacco, alcohol and other product taxes from tobacco, alcohol and other product taxes
into NCD preventioninto NCD prevention5.5. Ministers of Health: Ministers of Health: by mid 2008 develop action plan with by mid 2008 develop action plan with
other Ministriesother Ministries6.6. Physical education in schools : Physical education in schools : immediate reintroductionimmediate reintroduction7.7. Trans fats: Trans fats: eliminate progressively eliminate progressively 8.8. Nutritional labelling: Nutritional labelling: get regional system organisedget regional system organised9.9. Work site and other areas: Work site and other areas: new plans for physical activity new plans for physical activity
for the entire community for the entire community 10.10.Extensive public educationExtensive public education11.11.SurveillanceSurveillance12.12.CARICOM:CARICOM: continue development of action plans continue development of action plans
Peru summit with President Dec. 2007Peru summit with President Dec. 2007
1.1. Collaboration Collaboration between PAHO, WHO & President's officebetween PAHO, WHO & President's office2.2. Establish national mechanism: "Crecer" (to grow) : Establish national mechanism: "Crecer" (to grow) :
selective help for poorselective help for poor3.3. Money: $800million for Crecer Money: $800million for Crecer 4.4. Legislation: proposed emphasis on tobacco: Legislation: proposed emphasis on tobacco: ban sale ban sale
marketing etc to children, tax, limit accessmarketing etc to children, tax, limit access5.5. Minister of Health: Minister of Health: proposed change in medical proposed change in medical
curriculum; altered role for nurses: rural medical school curriculum; altered role for nurses: rural medical school 6.6. Teachers role: Teachers role: need new strategies for formal education need new strategies for formal education
in the poor areas - 60% female illiteracy in very poor in the poor areas - 60% female illiteracy in very poor highland and jungle areas of Peruhighland and jungle areas of Peru
7.7. Trans fats: Trans fats: eliminate progressively eliminate progressively 8.8. Nutritional labelling: Nutritional labelling: suggested newsuggested new regional system regional system
organisedorganised9.9. Work site and other areas: Work site and other areas: business involvement business involvement 10.10.Water and sanitary improvements Water and sanitary improvements 11.11.Regional PAHO initiative?Regional PAHO initiative?
Asia - Oceania InitiativesAsia - Oceania Initiatives
• ChinaChina: 10min play in schools!: 10min play in schools!• IndiaIndia: new Public Health Institutes! : new Public Health Institutes! • AustraliaAustralia: States vs Canberra. Marketing restrictions;$10b : States vs Canberra. Marketing restrictions;$10b
diabetes prevention plandiabetes prevention plan• New ZealandNew Zealand: frustration with academics , NGOs; school : frustration with academics , NGOs; school
& Maori initiatives: food industry consults; special task & Maori initiatives: food industry consults; special task force: Jim Mann.force: Jim Mann.
• Pacific IslandsPacific Islands: action plan - nothing happening: : action plan - nothing happening: proposals on junk food dumping sabotaged by Australia proposals on junk food dumping sabotaged by Australia and New Zealandand New Zealand
• SingaporeSingapore: Childhood programme just changed: Childhood programme just changed• MalaysiaMalaysia: New Global Alliance - educational priority: : New Global Alliance - educational priority:
Minister proposal on marketing junk food sabotaged by Minister proposal on marketing junk food sabotaged by food industry and Nutrition Soc. reps food industry and Nutrition Soc. reps
• PakistanPakistan: focus on heart disease and diabetes : focus on heart disease and diabetes
Proposals for early UK Government action October 1997Proposals for early UK Government action October 1997
• StopStop: : a) selling school play areas & sports facilities b) eliminating catering facilities b) eliminating catering facilities
• Public/privatePublic/private partnershipspartnerships
• Capital improvementsCapital improvements - link with new integrated - link with new integrated community planscommunity plans
• Health Promoting Schools UnitHealth Promoting Schools Unit:: establish in the DfEE.establish in the DfEE.
• Nutritional standardsNutritional standards for school meals needed for school meals needed
• Change food cultureChange food culture within schools. within schools.
• Set meals in primary schoolsSet meals in primary schools rather than cash cafeterias rather than cash cafeterias
• Tuck shops and vending machinesTuck shops and vending machines: improve: improve
• Food sold close to schoolFood sold close to school: how improve? : how improve?
• School Health ServicesSchool Health Services: new role; identified funding.: new role; identified funding.
• Village CollegeVillage College approach to schools approach to schools
• Free school mealsFree school meals for families just above income support for families just above income support level? level?
ConclusionsConclusions• Greater societal challengeGreater societal challenge with cancer &obesity than with cancer &obesity than
cardiovascular diseases which can be limited by "readily" cardiovascular diseases which can be limited by "readily" manipulated changes in food compositionmanipulated changes in food composition
• Toxic carcinogenic & obesogenic environmentToxic carcinogenic & obesogenic environment needs needs major changes. To improve societal body fat levels need big major changes. To improve societal body fat levels need big external changes to overcome buffering by appetite control external changes to overcome buffering by appetite control
• Systematic multilevel changes:Systematic multilevel changes: need coherent 5-10 yr need coherent 5-10 yr adaptable plan led by Governmentsadaptable plan led by Governments
• Industry can helpIndustry can help with specified regulations & 5 yr projected with specified regulations & 5 yr projected changeschanges
• External public health groups/bodyExternal public health groups/body: drive change, report to : drive change, report to Congress/States not White House; publicly transparentCongress/States not White House; publicly transparent
• Medical leadersMedical leaders should start working for the public Interest should start working for the public Interest
The cover of "The Economist", Dec. 13-19, 2003.