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.