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