23 James Final Lecture Summary and Immplementation

7/31/2019 23 James Final Lecture Summary and Immplementation

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The challenge of global cancer -The challenge of global cancer -where do we go next?where do we go next?

Philip JamesPhilip James

IPAIDF IOTF

IUNS WHF

LSHTM and Chair of IOTF and thePresidential Council of the Global Prevention Alliance


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The big issues?The big issues?

AnalyticalAnalytical: hopeless measures of diet: a: hopeless measures of diet: afresh look at biomarkers?fresh look at biomarkers?

GenotypingGenotyping - selective benefits if dealing- selective benefits if dealing

with specific processes e.g. alcoholwith specific processes e.g. alcoholdehydrogenasesdehydrogenases,, cytochromecytochrome transferasestransferasesmetabolising a single potential carcinogenmetabolising a single potential carcinogenrather than complex systems like obesityrather than complex systems like obesity

which results from numerous interactingwhich results from numerous interactingmechanismsmechanisms

Biological markers of cumulative andBiological markers of cumulative andspecific DNA changespecific DNA change: we still need to move: we still need to moveinto analogous stage of cardiovascularinto analogous stage of cardiovasculardisease with LDL and HDL cholesterol,disease with LDL and HDL cholesterol,inflammatory and hormonal markers withinflammatory and hormonal markers with

intermediate indices of arterial damage.intermediate indices of arterial damage.


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Nutritionally related risk factors contributing to globalNutritionally related risk factors contributing to global

cardiovascular diseasecardiovascular disease

Modifiable risk factors for myocardial infarction: PAR%Modifiable risk factors for myocardial infarction: PAR%

ApoB/ApoA1 ratio( topApoB/ApoA1 ratio( top vsvs lowest quintile): 49.2lowest quintile): 49.2

Smoking (current & formerSmoking (current & former vsvs never): 35.7never): 35.7

Psychosocial factors: 32.5Psychosocial factors: 32.5

Abdominal obesity(topAbdominal obesity(top vsvs bottom tertile): 20.1bottom 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: 6.76.7

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.


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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 smoked

Stopped smoking

20 cigarettes/day

The importance of diet in amplifying smoking's cardiovascular effects

From: Keys A. (Ed). Seven countries. A multivariate analysis of death and coronary heartdisease. Cambridge, MA, US: Harvard University Press, 1980.


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% Dietary energy from saturated fatty acids0 5 10 15 20 25

0

200

400

600R = 0.84

CorfuS. Italian

Crete

S. Italian

JapanYugoslavia

10-year coronary mortality in men


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The Keys concept of metabolic epidemiology plusThe Keys concept of metabolic epidemiology plus

volunteer feeding studies in cardiovascular diseasevolunteer feeding studies in cardiovascular disease- applicable to cancer studies?- applicable to cancer studies?

Blood

cholesterolLevels

Saturated fat intakesLow High

Increasingrisk ofheart

disease


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Deaths from

stroke in

different

Europeancountries,

plotted againsturinary salt

excretion,

derived fromthe

INTERSALTdata

7.5 8.0 8.5 9.0 9.5 10.0 10.5

Malta

N.IrelandFinland

Portugal

Belgium

Denmark

Iceland

Holland

GermanyEngland &Wales

Italy

Spain

r=0.832

p


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What does the Second Report really say?What does the Second Report really say?

The man in the street's questionsThe man in the street's questions

What are my chances of getting cancer in a) myWhat are my chances of getting cancer in a) my

life-time b) over the next 5-10 years?life-time b) over the next 5-10 years? Can you give me a chart so I can work out howCan you give me a chart so I can work out howmuch benefit I'll get from what you suggest -much benefit I'll get from what you suggest -which are my best buys?which are my best buys?

If I like processed meat exactly how much moreIf I like processed meat exactly how much morerisk am I eating it every day vs. once/wk?risk am I eating it every day vs. once/wk?

How much lower risk will I have if I becomeHow much lower risk will I have if I become

physically active, eat fibre rich foods or drop myphysically active, eat fibre rich foods or drop myalcohol intake?alcohol intake?

What does a bigger "relative risk" per unit alcoholWhat does a bigger "relative risk" per unit alcoholor vegetables mean when I don't know myor vegetables mean when I don't know my

current risk?current risk?


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Age

180 6 6 7 8 10 12 13 15 17 20

160 4 4 5 6 7 8 9 10 12 14

140 2 3 3 4 5 5 6 7 8 10 65

120 2 2 2 3 3 4 4 5 6 7

180 3 4 4 5 6 7 8 9 11 12

160 2 2 3 3 4 5 5 6 7 8

140 1 2 2 2 3 3 4 4 5 6 60

120 1 1 1 2 2 2 2 3 3 4

180 2 2 2 3 3 4 4 5 6 7

160 1 1 2 2 2 3 3 3 4 5

140 1 1 1 1 1 2 2 2 3 3 55

120 0 1 1 1 1 1 1 2 2 2

180 1 1 1 1 2 2 2 3 3 4

160 1 1 1 1 1 1 1 2 2 2

140 0 0 1 1 1 1 1 1 1 2 50

120 0 0 0 0 0 1 1 1 1 1

180 0 0 0 0 0 0 0 0 1 1

160 0 0 0 0 0 0 0 0 0 0

140 0 0 0 0 0 0 0 0 0 0 40

120 0 0 0 0 0 0 0 0 0 0

12 14 17 20 23 24 27 31 36 42

8 10 12 14 16 17 19 23 26 31

6 7 8 10 12 11 13 16 19 23

4 5 6 7 8 8 9 11 13 16

8 10 12 14 16 17 19 22 26 31

6 7 8 9 11 11 13 16 19 22

4 5 5 7 8 8 9 11 13 16

3 3 4 5 6 5 6 8 9 11

5 6 8 9 11 11 13 15 18 21

4 4 5 6 8 7 9 10 13 15

2 3 4 4 5 5 6 7 9 11

2 2 2 3 4 3 4 5 6 7

3 4 5 6 7 7 8 9 11 14

2 3 3 4 5 5 5 7 8 10

2 2 2 3 3 3 4 4 5 7

1 1 1 2 2 2 3 3 4 5

1 1 1 2 2 2 2 3 3 4

1 1 1 1 1 1 2 2 2 3

0 1 1 1 1 1 1 1 2 2

0 0 0 1 1 1 1 1 1 1

15% and over

10%14%69%

45%

3%

2%

1%

< 1%

10-year risk offatal CVD

in areas of

high CVD risk

Women Men

Non-smoker Smoker Non-smoker Smoker

HEARTSCORE, Conroy et al. Eur Heart J, 2003


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% Dietary energy from saturated fatty acids

10-yr.C

0 5 10 15 20 25

0

200

400

600R = 0.84

Corfu

S. Italian

Crete

S. Italian

JapanYugoslavia

10-year coronary mortality in men - Seven Country Study

The striking contrastThe striking contrast

in global nutritionalin global nutritionalproblemsproblems


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Foci for action inFoci for action in

relation to cancerrelation to cancer AlcoholAlcohol

Salt/pres. methodsSalt/pres. methods

Some meatsSome meats

Fats- esp. transFats- esp. trans SugarsSugars

VegVeg/fruits/cereals/fruits/cereals (whole grain)(whole grain)

Physical activityPhysical activity

ObesityEnergy Density


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Energy density (kJ 100 g-1)

Fa

tcontent(g1

00g

-1)

Burgers

Fried chicken

Fries (chips)

S'market

healthy options

S'market readymeals (Indian)

S'market pies, pasties

Gambian main meals

S'market readymeals (Italian)

S'market pizzas

FAST FOODSFAST FOODS

SUPERMARKET READYSUPERMARKET READY

MEALSMEALS

GAMBIAN +GAMBIAN +

HEALTHY CHOICEHEALTHY CHOICE

Prentice AM & JebbSA. Obesity Reviews,2003, 4: 187-194

The energy density of different foods is markedlyThe energy density of different foods is markedly

influenced by their fat contentinfluenced by their fat content


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Covert manipulation of energy density: effects on intake

Prentice AM & Jebb SA. Obesity Reviews, 2003, 4: 187-194


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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


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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

IRL NL*

ITFIN

UK

= range of member state recommendations for these nutrients

Institute of European Food Studies (IEFS) Ireland. 2000


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The traditional Mediterranean diet

Corfu & Crete

1960-65 Men (7country) g/d

S. Italy

1930s Household(CNR) per caput g/d

EURATOM

1960s Householdg/d/consumption unit

S. Italy

1960-65 Men (7country) g/d

0

250

500

750

1000

1250

1500Fish

Fruit

Vegetables

Cereals

Fats & oils

Milk

Meat

Eggs

Alcohol

Sugars etc.


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A quarter-pound cheeseburger,A quarter-pound cheeseburger,

large fries and a 16 oz. sodalarge fries and a 16 oz. soda

provide:provide:

1,166 calories1,166 calories

51 g fat51 g fat

95 mg cholesterol95 mg cholesterol

1,450 mg sodium1,450 mg sodium


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The keys to success in the foodThe keys to success in the food

business and in obesity and chronicbusiness and in obesity and chronicdisease preventiondisease prevention

PricePrice

AvailabilityAvailability

MarketingMarketing


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Children's fruit purchasesChildren's fruit purchases

depend on pricedepend on price


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Real food prices and early childhood obesityReal food prices and early childhood obesity

0.3

0.2

0.1

0

-0.3

-0.2

-0.1

-0.4

Mean BMI increases compared with average

Visana, CA

Pittsburgh,PA

Chicago, IL

New Orleans LA

Houston, TX

Mobile, AL

Increasing relative cost of fruit and vegetablesIncreasing relative cost of fruit and vegetables

Adapted from Sturm R and Datar A. Body mass index in elementary school children, metropolitan area foodprices and food outlet density. Public Health, 2005. In Press, October 2005.


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The fall in the cost of agricultural commoditiesThe fall in the cost of agricultural commodities

1960-20001960-2000

Based on world market prices related to 1990


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The progressive fall in sugar prices in association withThe progressive fall in sugar prices in association with

marked increases in global production stimulated bymarked increases in global production stimulated by

huge government subsidieshuge government subsidies

World monthly refined

and raw sugar prices

Sources: Coffee, Sugar & Cocoa Exchange, In., & London International Futures Exchange


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Government support for producing grain and oilseed crops comes in many forms, frommoney 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.


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US farm subsidies $ billionUS farm subsidies $ billion

0

5

10

15

20

25

1995 1997 1999 2001 2003


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EU CAP ExpendituresEU CAP Expenditures

43.5 bn

Source: Schfer Elinder L., Public Health Aspects of EU CAP, 2003


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0

200

400

600

800

1000

0.01 0.1 1 10 100 1000

Energy cost (Euros/1000kcal)

Energy

density

(kcal/100

g)

oil

butter

sugar

desserts

milk

grainscheese

fruit

fish/shellfish

vegetables

nuts

pasta

Log scale!

High energy dense foods (kcal / 100g) cost less (High energy dense foods (kcal / 100g) cost less ( / 1000 kcal)/ 1000 kcal)

Darmon, Darmon, Maillot and Drewnowski, JADA, 2005


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4.6

11.1

22.2

3.35

12.5

28.5

3.4

11.5

14.5

45.4

8.7

17.818.9

39

15

0

10

20

30

40

50

China India Malaysia Thailand

G

ramsperc

apitaperd

ay

1965 1975

1985 1995

Increased vegetable oil consumption is a key componentof the shift in the stages of the Nutrition Transition in Asia

Source: Food Balance data, UNFAO


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Enormous cities, enormous food needs

Source: FAO, 1998b

By 2015, twenty-six cities in the world are expected tohave populations of 10 million or more. To feed a city ofthis size today - for example, Tokyo, Sao Paulo or MexicoCity - at least 6,000 tonnes of food must be importedeach day.

New York

Osaka

ShanghaiMexico City

Rio de Janeiro

Sao Paulo

BuenosAires

Los Angeles

Lagos

Cairo

Karachi

Delhi

Bombay

Dhaka

CalcuttaHyderabad

Beijing

Tianjin

Hangzhou

Seoul

Tokyo

Lahore

TeheranIstanbul

Jakarta

* Projected

1950

1975

2000*

2015*

Manilla

Cities withpopulations greaterthan 10 million since:


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11.. Alcohol 6.2%

2.2. Blood pressure 5.0%

3.3. Tobacco 4.0%

4.4. Underweight 3.1%

5.5. Overweight 2.7%6.6. Cholesterol 2.1%

7.7. Indoor smoke from solid fuels 1.9%

8.8. Low fruit and vegetable intake 1.9%9.9. Iron deficiency 1.8%

10.10. Unsafe water, sanitation & hygiene 1.7%

Leading DALYs in 2000: low mortality developing

countries

WHO World Health Report 2002


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%

0

10

20

30

40

50

60

70

80

90

100

110

18-25 25-27 27-29 =>30 18-25 25-27 27-29 =>30

Mexico US

BMI

p < 0.001

p < 0.001p < 0.005p > 0.05

Women 40-69 years,

Height 150-159 cm

p by chi-squaredNHS 2000,Mexico

Men 40-69 years,

Height 160-169 cm

p by chi-squared

p < 0.001

p < 0.001

p < 0.005

p > 0.05

Men WaistMen Waist 9494 cmcmWomen WaistWomen Waist 8080cmcm

NHANES III (1988-94)

Selective abdominal obesity in Mexico(US non-Hispanic whites data standardized to Mexican age structure)

W ld i


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Source: FAO data and projections

World average meat consumptionWorld average meat consumption

per person, 1964-66 to 2030per person, 1964-66 to 2030

1964-66 1997-99 2030

Consumption(kg/capita/yea

r)Beef

Pig meat

Sheep & goat meat

Poultry


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Nutritionists advocate a "balanced diet": the emergenceNutritionists advocate a "balanced diet": the emergenceof coronary heart disease in the Western worldof coronary heart disease in the Western world

UN Commission Report: Food & Nutrition Bulletin, 2000.

)


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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

7.2

Cholesterol

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


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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

Observedmortality

Smoking

Bloodpressure

All threerisks

Cholesterol


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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.

E l i b i i d lE l ti b it t i d lt


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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

bese(BMI=

>30kg/m2)

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 (Troms)

% Obese(BMI >30 kg/m2)

20022002

Obese: 356 millionO/wt >25: 1.4 billion

2007

Obese: 523 million

O/wt 25: 1.539 billion20152015

Obese: 704 millionO/wt >25: 2.3 billion

Global Totals

Projected overweight (incl obesity) rates forProjected overweight (incl obesity) rates for


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Projected overweight (incl. obesity) rates forProjected overweight (incl. obesity) rates for

school age childrenschool age children

Wang and Lobstein, IOTF, 2006.

0

510

15

20

25

30

35

40

45

50

Recent surveys Projected 2006 Projected 2010

Americas (1988-2002)

Eastern Med (1992-2001)

Europe (1992-2003)

South East Asia (1997-2002)

West Pacific (1993-2000)

e.g. China

e.g. India

%%

Prevalence

e.g. US

S.Arabia

e.g. UK

Global totalGlobal total

Obese 74 mil.Obese 74 mil.O/wt 287 mil.O/wt 287 mil.


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Annualized change in prevalence of overweightAnnualized change in prevalence of overweight

(including obesity) among European adolescents(including obesity) among European adolescents

-0.50

0.00

0.50

1.00

1.50

2.00

2.50

1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Mid-year

Annuali

ncrement(%

points)

girls, adolescents boys, adolescents

Linear (girls, adolescents) Linear (boys, adolescents)

Preliminary WHO data, 2007

Impact of weight gain on Diabetes in Asians & Caucasians:Impact of weight gain on Diabetes in Asians & Caucasians:


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Sanchez-Castillo et al Mexican Nat. Health Survey data Pub Health Nut. 2005;8:53-60Huxley R, James WPT et al. Obesity in Asia Collaboration. Ob. Rev. (in press 2007)

p g gp g g

also true of Hispanics & the Caribbeanalso true of Hispanics & the Caribbean

Asian Male

Caucasian Male

Asian Female

Caucasian Female

Asian Males

Asian

Females

CaucasianMales

Caucasian

Females

Diabetes35

30

25

20

15

10

5

0

16

5

20 24 28 32 36 40

BMI

%

WHOAsianlimit

O/W Obese

Derek Wanless report to UK Prime MinisterDerek Wanless report to UK Prime Minister


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Derek Wanless report to UK Prime MinisterDerek Wanless report to UK Prime Minister2004 & 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 illhealth, such as obesity, even higher levels of funding will beneeded over the next two decades to deliver the high-quality

services envisaged by the 2002 Wanless review."

Wanless D. Reports to the Treasury onPublic Health: First Report, 2002;

Second Report, 2004

Wanless et al. Our futureHealth Secured? Sept 11th

2007

I nd i v i dua l r espons ib i l i t yComplementaryComplementary


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e.g. Focus on Health Education - but

need understandable food labelling;campaigns selectively help upper

socio-economic groups

I nd i v i dua l r espons ib i l i t y

Chan ges t o t he" t o x i c" en v i r o n m en t

Adapted from Puska P, 2001

Progressively adapt all towns/cities to favourpedestrian/cycling as norm with car restrictions

Nutritional standards for food in all governmentfacilities/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/sugaryproducts; soft drinks

Social/employment/medical policies for breastfeeding as the norm

ComplementaryComplementaryapproaches toapproaches to

obesity &obesity &chronic diseasechronic diseasepreventionprevention

Prevalence of obesity in schoolchildren in SingaporePrevalence of obesity in schoolchildren in Singapore


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Prevalence of obesity in schoolchildren in SingaporePrevalence of obesity in schoolchildren in Singapore

weight (kg) for height (m) >120%weight (kg) for height (m) >120%

%

16

14

12

10

8

6

4

2

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

New growth charts used since 1994. Source: Ministry of Health, Singapore

Strategies for obesity and chronic diseaseStrategies for obesity and chronic disease


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Strategies for obesity and chronic diseaseStrategies for obesity and chronic disease

prevention - applicable to smoking, alcohol and foodprevention - applicable to smoking, alcohol and food

PricePrice

AvailabilityAvailability

MarketingMarketing

Tax high fat sugar and salt

products; tax marketing.Subsidise vegetables, fruits

Establish standards for

imports, local business, foodin all government supported

outlets. Recruit business

UK style nutritional profiling

for labels. Ban/restricttargeting children - TV,

schools, product placement

Annual obesity rate changes and response toAnnual obesity rate changes and response to


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School feedingmakes childrenobese

y g py g p

feeding programmes - March to Nov. each yearfeeding programmes - March to Nov. each year

3 to 4 yr. old pre-school children in Chile3 to 4 yr. old pre-school children in Chile

0

5

10

15

20

25

1992 2000 2004

March

November

%

Uauy R and Kain J. WHO Expert Consultation on childhood obesity.Kobe, Japan, 20-24 June 2005

School feedingmakes childrenobese!

New schoolfeedingprogramme

reversing obesity

Societal policies and processes influencing thepopulation prevalenceof obesity


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COMMUNITY

LOCALITY

Agriculture/Gardens/

Local markets

HealthCare

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

WorksiteFood &

Activity

LeisureActivity/Facilities

Family &Home

INDIVIDUAL

Energy

Expenditure

Foodintake :

Nutrientdensity

Soc eta po c es a d p ocesses ue c g t e popu at o p e a e ce o obes ty

NATIONAL/

REGIONAL

Education

Food &Nutrition

Urbanization

Health

Social security

Transport

Media &Culture

Nationalperspective

INTERNATIONAL

FACTORS

Development

Globalizationof

markets

Mediaprograms

& advertising

The Foresight causal map of obesityThe Foresight causal map of obesity


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The Foresight causal map of obesityThe Foresight causal map of obesity

IndivPhys

Activ..

Physical

ActivityEnvir.

Individual Psychology

Food

Production Intake

PhysiologyPhysiology

Societal PsychologySocietal Psychology

Fundamental changes in physical activity:Fundamental changes in physical activity:


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g p y yg p y y

inevitable and optional changesinevitable and optional changes

Inevitable: Rural to urban transition Labour changes;

Mechanisation/computerisation of standard work; alsohome duties e.g. cooking, washing, cleaning

Optional:

Urban building policies: high intensity or US style sprawl? Road and community design Office & supermarket location policies Car policies versus preference for cyclists/pedestrians

Policies on free spaces for children's play; lighting forsafety e.g. for older people Park/leisure/sports facilities/school PA lessons Ease of transport of perishable foods into towns/cities

Options for increasing physical activity to desirable 1.7 PAL


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1.58 1.72 1.70 2.50 2.30

0

100

200

300

400

500

600

700

800

900

1000

1100

1200

1300

1400

A normal

sedentary day

Timeallocationmins/day

From Ferro-Luzzi and Martino (1996). Modelling was performed for an average 70 kg male to determine the nature, durationand timing of active leisure required to achieve an overall mean physical activity level of around 1.70. Columns 2 and 3

indicate how this can be achieved by exercising on a daily basis, whilst columns 4 and 5 show what is required if exercise isconcentrated into one day per week.

Travel (BMR x2.56)

Domestic activity

(BMR x 2.82)

Work (BMR x 1.60)

Active leisure

Passive leisure

Sleeping,washing etc.(BMR x 1.06)

The day's PAL

Jog 20'BMRx11.0

Walk 60'BMRx4.0

Jog 140'

BMRx11.0Walk 420'BMRx4.0

Daily Once weekly

ALTERNATIVE STRATEGIES

Roads within 500m of a postcode in Sandwell, West Midlands, UK whichcontain one or more shops where food is reasonably priced and which sell


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contain one or more shops where food is reasonably priced and which sellmore than 8 kinds of fresh fruit and vegetables

Source: Dowler, Blair et al. 2001

Roads within 500m

Roads further than 500m

Railways

Canals & streams

Shops*

Who controls the food chain ?Who controls the food chain ?


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Corinna Hawkes, 2006

Local markets,Local markets,

roadside stallsroadside stalls

and farm shopsand farm shops

Supermarkets: the

"food consuming industry"

SmallSmall

foodfood

outletsoutlets

GENERAL POPULATION

Global Feed CompaniesGlobal Feed Companies

Global Food Companies

FarmersFarmers (large Government subsidies)(large Government subsidies)

Family and otherFamily and other

small foodsmall food

companiescompanies

Altering sales tax but preservingAltering sales tax but preserving


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Altering sales tax but preservingte g sa es ta but p ese g

revenue in Denmarkrevenue in Denmark Reduce vegetable, fruit, wholegrainReduce 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

NBNB::income to government unchangedincome to government unchanged

Smed S & Denver S. Food & Resource Economics Ints. KVL Univ., Denmark, April 2005.

Manipulating sales taxes can benefitManipulating sales taxes can benefith di f h


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the diet of the poorthe diet of the poor

Smed S & Denver S. Food & Resource Economics Ints. KVL Univ., Denmark, April 2005.

-20

0

20

40

60% Intake changes

Saturated fat

Sugar

Fibres

1 2 3 4 5SOCIAL CLASSSOCIAL CLASS

The richThe rich the poorthe poor

Marketing to ChildrenMarketing to Children


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Marketing to ChildrenMarketing to Children

Manipulating children's behaviour: evidenceManipulating children's behaviour: evidence

f h UK ' i l i


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Food industry promotions:Food industry promotions:Can confuse nutritional knowledge,Can confuse nutritional knowledge,

e.g. whether fruit is in producte.g. whether fruit is in product

Change food preferencesChange food preferences

Change purchasing behaviourChange purchasing behaviour Influence choice and consumption byInfluence choice and consumption by

brandbrand Alter balance of food categoriesAlter balance of food categories

eateneaten

from the UK government's systematic analysisfrom the UK government's systematic analysis

Hastings Report, UK Food Standards Agency, 25th September, 2003.

Proposals for early Government action October 1997Proposals for early Government action October 1997


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StopStop:: a) selling school play areas & sports facilities

b) eliminating catering facilitiesb) 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 theestablish in the DfEEDfEE..

Nutritional standardsNutritional standards for school meals neededfor school meals needed

Change food cultureChange food culture within schools.within schools. Set meals in primary schoolsSet meals in primary schools rather than cash cafeteriasrather 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 schoolsapproach to schools

Free school mealsFree school meals for families just above income supportfor families just above income support

level?level?

Consumer purchases with traffic light food labelling ofConsumer purchases with traffic light food labelling ofnutrients as proposed by UK's Food Standards Agency.nutrients as proposed by UK's Food Standards Agency.


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nutrients as proposed by UK s Food Standards Agency.p p y g yHealthy (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 356all 5GREENon WoH

42%

55%

Wheel of HealthWheel of Health

(WoH)(WoH)

'Taste the Difference'

Melting Middle Chocolatepuddings

4 red, 1 amber

'Be Good to Yourself'

Chocolate sponge

puddings4Green, 1 amber

42%

89%

Sainsbury's Supermarketpresentation to The National

Heart Forum, UK., 2006.

Illustration of the GDA systemIllustration of the GDA system


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Illustration of the GDA systemIllustration of the GDA system

GDA labelling shows percentages of guideline dailyamounts per serving

WHO

Formulating a nutrition policy for the prevention of obesity and chronic disease


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WHO

Health statisticsDietary & risk fact.surveys

Nutritional surveillance

Food productionAgriculturalFood production statistics

Market structureImport/export policies

Food security measures

Public perceptionEconomic evaluation of

policy proposals

National Information

FAO, UNICEF, UNESCO, WTO, World Bank etc.

MINISTRY of HEALTH(HEALTH POLICY

GROUP)

INDEPENDENTNATIONAL

INSTITUTION

Nongovernmental

organizations andconsumer

representatives

Ministry of health actions1. Professional training2. Health promotion

national networks (NGO, voluntary Orgs.)national campaign

3. Regional and district food policy4. Catering establishments5. Priorities, research and surveillance

Actions

Ministry of Education

Ministry of Information

Ministry ofAgriculture/Environment

Ministry of Trade

Ministry of Finance

Ministry of Foreign

Affairs

school & postgraduateeducation

school meals

coordinating

educational materials

re-evaluation of currentpolicies

controls on foodindustry

licensing, cooperativetrade arrangements

tax, subsidyadjustments

policy on import /export trade

coordinatingregional actions

Private sector

Potential mechanisms for combatingPotential mechanisms for combating


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ote t a ec a s s o co bat gg

distorted marketsdistorted markets1.1. Reorganise agricultural policies to bring in line withReorganise agricultural policies to bring in line with

health needs.health needs.

2.2. Substantial increase in agricultural R&D, withSubstantial increase in agricultural R&D, withextension work involving farmers (especially women)extension work involving farmers (especially women)

3.3. Focus on special urban storage, refrigerationFocus on special urban storage, refrigeration

facilities and transport lines for rural products e.g.facilities and transport lines for rural products e.g.fruit, vegetables (WCRF 1fruit, vegetables (WCRF 1stst report)report)

4.4. Identify principal buyers for supermarkets, importers:Identify principal buyers for supermarkets, importers:

need to engage in conjoint quality assurance onneed to engage in conjoint quality assurance on

nutrient goals - current understanding negligiblenutrient goals - current understanding negligible

5.5. Introduce national signposting (not ticks) for all foodIntroduce national signposting (not ticks) for all food

products based on UK Food Standards Agencyproducts based on UK Food Standards Agency

scheme but criteria based on WHO global goalsscheme but criteria based on WHO global goals

World PrioritiesWorld Priorities


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Copenhagen Consensus 2004Copenhagen Consensus 2004 climate change,

communicable diseases, conflicts and arms proliferation,

education,

financial instability,

governance and corruption,

malnutrition and hunger,

migration, sanitation and clean water,

subsidies and trade barriers.

The interest and influences of different stakeholdersThe interest and influences of different stakeholders

Health


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INFLUENCEINFLUENCE

-10

-5

0

5

10

IN

TEREST

IN

TEREST

Children

Healthprofessionals

Advocacy orgs.

Scientists

ParentsMinistry of Health

Parliament

Farmers

Media

Church

Ministries of

Transport& Agriculture

Retailers

Treasury

President

Advertisingindustry

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.


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ConclusionsConclusions


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Greater societal challengeGreater societal challenge with cancer &obesity thanwith cancer &obesity thancardiovascular 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 needsneedsmajor changes. To improve societal body fat levels need bigmajor changes. To improve societal body fat levels need bigexternal changes to overcome buffering by appetite controlexternal changes to overcome buffering by appetite control

Systematic multilevel changes:Systematic multilevel changes: need coherent 5-10 yrneed coherent 5-10 yr

adaptable plan led by Governmentsadaptable plan led by Governments Industry can helpIndustry can help with specified regulations & 5 yr projectedwith specified regulations & 5 yr projectedchangeschanges

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 Interestshould start working for the public Interest


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The cover of "The Economist", Dec. 13-19, 2003.


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23 James Final Lecture Summary and Immplementation

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