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The dietary challenge in the The dietary challenge in the CaribbeanCaribbean
Philip JamesPhilip James
IPAIDFIOTF
IUNS WHF
LSHTM and Chair of IOTF and thePresidential Council of the Global Prevention Alliance
OBESITY
Dietary changeDietary change
Phytoestrogensbioactivate molecules
Folate, B6
Homocysteinaemia ? Thrombosis
Sex hormone changes
Trans fatty acidsn-3 fatty acids
Saturated fats
Atherosclerosis
Antioxidants
Total Fat
High energy density * by fat & refined CHOs
Physical inactivityPhysical inactivity
Cytokines etc.
DIABETES CHD
HYPERTENSION
CANCERS: e.g. breast, colon, endometrium
++
+ + +
+
+
+
+
+
+
+
+
+ + +
++
* Energy density reduced by water-holding, bulky foods, e.g. tubers, cereals, vegetables, fruits, pulses.
Vegetables, fruits, pulses
A summary of the nutritional problems in A summary of the nutritional problems in the Caribbeanthe Caribbean
• ChildhoodChildhood malnutrition:malnutrition: dramatic fall dramatic fall• StrokesStrokes: caused by high : caused by high saltsalt intakes: amplified intakes: amplified
by weight gain, dietary by weight gain, dietary fatfat, , low fruit and low fruit and vegetablevegetable intakes intakes
• Coronary heart disease Coronary heart disease emerged asemerged as saturatedsaturated fat fat intakes riseintakes rise
• Obesity/diabetesObesity/diabetes: physical activity falls ;: physical activity falls ;energy energy densitydensity from high fat/sugar low F&V diets from high fat/sugar low F&V diets
• Huge change needed at multiple levels : personal, family, community and national
Foci for action in relation to chronic Foci for action in relation to chronic diseasesdiseases
• AlcoholAlcohol• Salt/pres. methodsSalt/pres. methods• Some meatsSome meats• Fats- esp. trans Fats- esp. trans • SugarsSugars
• Veg/fruits/cereals Veg/fruits/cereals (whole grain)(whole grain)
• Physical activityPhysical activity
ObesityEnergy Density
Systematic review of tobacco prevention strategiesSystematic review of tobacco prevention strategiesUS DHSSUS DHSS
• Strong evidence of effectiveness for: increasing the unit price of tobacco products
and mass media campaigns run concurrently with other interventions.
• Sufficient evidence of effectiveness for: restricting tobacco product distribution, regulating the mechanisms of sale, enforcing access-to-minors laws, merchant education and training all conducted in conjunction with community
mobilization
Ranney et al Tobacco Use: Prevention, Cessation, and Control Evidence Report/Technology Assessment
Number 140 US DHSS 2006
UK British Medical Association proposals UK British Medical Association proposals to reduce alcohol abuseto reduce alcohol abuse
• Increase priceIncrease price
• End sponsorshipEnd sponsorship by alcohol producers of by alcohol producers of sporting and entertainment events that sporting and entertainment events that have a young target audience; have a young target audience;
• LegislateLegislate on labelling of alcohol products on labelling of alcohol products
• Reduce drink driving limitReduce drink driving limit: 80 50mg/dl: 80 50mg/dl
• Random breath testingRandom breath testing
BMA annual representative meeting, Torquay, 25 June to 29 June 2007
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
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.
• Chronic over-production of Chronic over-production of sugar and buttersugar and butter
1 cent for 100 kcal1 cent for 100 kcal
55 cents for 100 kcal55 cents for 100 kcal
Agriculture policyAgriculture policy
• Low cost of calories from Low cost of calories from oils, sugars, starchesoils, sugars, starches
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 eye-tracking technology to detect Current eye-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"?
USA
Adapted from Bray & Popkin, AJCN 1998; 68: 1157-1173 with data from FAO 2005, CFNI and recent national surveys
Dietary fat and weight gain : additional effects of high Dietary fat and weight gain : 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
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
Mali
China 1982
India Congo
TunisiaMalaysia
Australia
New Caledonia
ItalyBrazilCuba
S. Africa
r = 0.88r = 0.88
Barbados
Guyana
Trinidad & Tobago
Jamaica
+ 20% sugar
2002
Russia
Philippines
Kyrgyzstan
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
Eating healthily in different food Eating healthily in different food outlets: how do I tell what I am eating?outlets: how do I tell what I am eating?
• HomeHome
• School/workSchool/work
• FriendsFriends
• Canteens/ Restaurants/ fast food outlets Canteens/ Restaurants/ fast food outlets
• Street foodsStreet foods
• Vending machinesVending machines
• CafCafééss
Who controls the food chain in the Who controls the food chain in the Caribbean? Not the people!Caribbean? Not the people!
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 Food Companies
FarmersFarmers
Family and other Family and other small food small food companiescompanies
International fast food
franchises
IMPORT CONTROLS
Key buyers & food importers
Central policies affecting the general Central policies affecting the general populationpopulation
• Nutritional Profiling of foods: new Nutritional Profiling of foods: new UK policy being extended to Europe UK policy being extended to Europe & Asia: applicable to school food& Asia: applicable to school food
• Labelling with consumer relevant Labelling with consumer relevant symbols, e.g. traffic lights with symbols, e.g. traffic lights with nutritional profiling: dramatic impact nutritional profiling: dramatic impact on sales – understandably resisted on sales – understandably resisted by vulnerable business interests.by vulnerable business interests.
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 - "Which"Organisation - "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 in the Who controls the food chain in the Caribbean? Not the people!Caribbean? Not the people!
Local markets, Local markets, roadside stalls roadside stalls
and farm and farm shopsshops
Supermarkets: the "food consuming
industry"
Small Small food food
outletsoutlets
GENERAL POPULATION
Global Food Companies
FarmersFarmers
Family and other Family and other small food small food companiescompanies
International fast food
franchises
Key buyers & food importers
Nutritional profiling determining government policies throughout the food chain IMPORT CONTROLS
Deaths from stroke in different European countries, plotted against urinary salt excretion, derived from the INTERSALT data
Deaths from stroke in different European countries, plotted against urinary salt excretion, derived from the INTERSALT data
7.5 8.0 8.5 9.0 9.5 10.0 10.5
Malta
N.IrelandFinland
Portugal
Belgium
Denmark
IcelandHolland
GermanyEngland & Wales
ItalySpain
r=0.832p<0.001
2210
1810
1480
1210
990
810
670
550
Urinary salt excretion (g/day)
Dea
ths
fro
m s
tro
ke(p
er 1
00,0
00 p
er y
ear)
Sodium in tap water Cooking salt
Manufacturers’ salt in processed food
Natural sodium content of foods
Discarded salt in cooking water
Discarded salt on plate (food, water, cooking & table salt sources in variable proportions)
Sodium ingestedSodium ingested
Plated salted food
* * *
* **
* * * **
* * ****
The tracking of cooking salt consumptionThe tracking of cooking salt consumption
Defining cooking salt intakes for patient counselling and policy making. Sanchez-Castillo & James. 1995.
18%
59%7%
8%7%
0
2
4
6
8
10
Gra
ms
/ day
Non-salt food additives
Natural
Cooking
Water and Medicines (1%)
Table
Added salt
18%
59%7%
8%7%
0
2
4
6
8
10
Gra
ms
/ day
Non-salt food additives
Natural
Cooking
Water and Medicines (1%)
Table
Added salt
Salt sources in a Western dietSalt sources in a Western dietSalt sources in a Western dietSalt sources in a Western diet
Derived by the lithium technique: James et al., Lancet,1987; 1: 426-429. Edwards et al. Eur J Clin Nutr 1989 43:855-61
**
*
18%
59%7%
8%7%
0
2
4
6
8
10
Gra
ms / d
ay
Non-salt food additives
Natural
Cooking
Water and Medicines (1%)
Table
Added salt
18%
59%7%
8%7%
0
2
4
6
8
10
Gra
ms / d
ay
Non-salt food additives
Natural
Cooking
Water and Medicines (1%)
Table
Added salt
Salt sources in UK and Italian diets Salt sources in UK and Italian diets Salt sources in UK and Italian diets Salt sources in UK and Italian diets
Derived by the lithium technique: James et al., Lancet,1987; 1: 426-429. Edwards et al. Eur J Clin Nutr 1989 43:855-61;Italian data: Leclercq & Ferro-Luzzi Eur J Clin Nutr 1991,3,151-159
**
*
Total discretionary salt in Italy in late 1980s : 34 - 39%
Total Salt intakes in Italy similar to UK: 11.1g in men; 9.3.g in women and 7.7g/d in children
: : food processing
Intervention trial in two Portuguese villages
70
80
90
100
110
120
130
140
150
160
170
*p<0.05, ***p<0.001 compared to control group
0 1Years
2
*** ***
* ***B
lood
pre
ssur
e (m
mH
g) (
+S
EM
)
Control Moderate salt restrictionForte et al. (1989) J Human Hypertension, 3, 179-184.
Components of an integrated comprehensive Components of an integrated comprehensive model for school-based obesity prevention.model for school-based obesity prevention.
School
food services
Nutrition environment of the school
School health
services Health instruction
(curriculum)
School counselling and
psychology programs
Family and community
linkages
Physical education
classes
School-site health promotion for
faculty and staffGoal: enhancing
healthy eating practices and physical activity patterns and
achieving healthy weights in children
and adolescents
Salt restriction for six months in newborn babies
Ad
just
ed d
iffe
ren
ce i
n b
loo
d p
ress
ure
(m
mH
g)
Double blind Normal salt
Normal salt
Moderate reduction salt
p<0.01p<0.02
1
0
-1
2
-3
-45 9 13 17 22 25
Age (weeks)15
Yearsn=167
Difference in blood pressure in newborn babies, randomised to either a normal salt intake or a moderate reduction in salt intake over the first six months of life. At six months, the study was discontinued, with all participants resuming a normal salt intake. Fifteen years later, a subgroup of those in the study had blood pressure re-measured.
McGregor, GA. (1999) Nutr Metab Cardiovascular Dis, Suppl.4, 6-15
1g extra salt: soft drinks 27 ml/d and water 100 ml/d in British children aged 4-18 yrs
Salt intake is related to soft drink consumption in children & adolescents: a link to obesity? He, Marrero & MacGregor. Hypertension. 2008 Mar;51(3):629-34
Restrict promotion of energy-dense, nutrient poor foods and beverages ….while allowing the promotion of foods .. in line with the WHO dietary recommendations *
Imperative to protect all children
Incorporate all forms of marketing
* IMPLIES NEED FOR NUTRIENT PROFILING
5 Practical Priorities: local activism by business 5 Practical Priorities: local activism by business and NGOs leads to major changes and NGOs leads to major changes
• Major drive to increase/ sustain breast feedingMajor drive to increase/ sustain breast feeding: facilities at work important; maternal leave + cultural change
• Marketing restrictionsMarketing restrictions (not just TV advertising) - statutory for children & adolescents: rights of child extend to 18 yrs
• Control of foodControl of food in nurseries, all school facilities and school environment: avoid choice - all foods of high nutritional quality + facilities to allow spontaneous play - not TV; most measures apply to all public/private facilities
• Fruit and vegetable availabilityFruit and vegetable availability within main cost in canteens and restaurants - government + local action
• Transformation of physical facilities for spontaneous & Transformation of physical facilities for spontaneous & leisure time activityleisure time activity: urban design changes with novel traffic policies; pedestrian only areas immediately adjacent to houses/apartments
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
Governmental/community initiatives Governmental/community initiatives are the most cost-effective are the most cost-effective
Schools
Federal / National Parliament
Regional
Local Council Local Council Local Council
Schools Schools SchoolsSchools
GENERAL POPULATION
IMPACT COSTS
Minimum
Maximum
Maximum
Minimum
Foresight: predicted diabetes costs with Foresight: predicted diabetes costs with different prevention strategiesdifferent prevention strategies
2004 2014 2024 2034 2044
M£/Yr
1049
654
240
-164
-366
BMI Cap 30
20+yrs: BMI -4 units
Prevent children's
obesity
No action
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
Nutritionists advocate a "balanced diet": the emergence of coronary heart disease in the Western world. Its reversal by
coherent multiple level actions involving regulatory measures.
Annual mortality per 100.000
FranceSpain
Greece
Norway
National Comparisons Males 0-64yrsNational Comparisons Males 0-64yrsAdults 50-59yrsAdults 50-59yrs
1925 2005
NorwayNorway
Year