Social and individual Social and individual responsibilities for the prevention responsibilities for the prevention

of chronic diseasesof chronic diseases

Philip JamesPhilip James

IPAIDFIOTF

IUNS WHF

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

The range of issues to be considered The range of issues to be considered

• All societal initiatives that are not the exclusive concern of government

• Previous effective action & policy proposals used

• Development of coherent plans based on analyses & experience in each domain

• Role of government in promoting these social and individual developments?

• When to initiate these developments and how should they be assessed?

WHO initiatives for action on chronic diseases

First presentation of the major risk factors

explaining the burden of sickness and early death

across the world

2002 2003

The update on the evidence on diet

and physical activity in relation

to chronic diseases

2004

The Member State agreed WHO Global strategy on diet and

physical activity

Some WHO background documents in Some WHO background documents in addition to PAHO initiativesaddition to PAHO initiatives

WHO Obesity Report 2000

WHO Euro Nutrition Action plan 2004

WHO/EU Ministers of Health meeting, Istanbul

Nov.2006

Extensive set of proposals for

prevention

Details of intersectoral needs

Proposals for new systems of care and

societal change

National initiatives. UK: the current National initiatives. UK: the current obesity challengeobesity challenge

Obesity is a normal "passive" biological response to our changed physical and food environment

Some children/adults are more susceptible for genetic, social and economic reasons

Overwhelming environmental impact reflects outcome of normal industrial development

Obesity reflects failure of the free market

UK Government report Oct. 2007

The current obesity dilemmaThe current obesity dilemmaObesity similar to climate change:

1. Numerous forces involved: societal and industrial developments

2. Action essential now - exceptionally difficult to reverse

3. No single remedy will suffice

4. Co-ordinated central and local government, industrial, societal and individual changes necessary

5. Major changes needed - not just individual advice to eat less and walk more!

6. Immediate action necessary although many logical remedies remain unproven

UK Government Report Oct. 2007

New Regional initiatives: Trinidad summit proposals of New Regional initiatives: Trinidad summit proposals of Prime Ministers with PAHO on September 15Prime Ministers with PAHO on September 15thth -17 -17thth 2007 2007

1. Collaboration between CARICOM, PAHO, WHO & partners!2. Establish National Commissions3. Legislation - immediate implementation tobacco framework:

ban sale marketing etc to children, tax, limit4. Money: from tobacco, alcohol and other product taxes into

NCD prevention5. Ministers of Health: by mid 2008 develop action plan with other

Ministries6. Physical education in schools: immediate reintroduction7. Trans fats: eliminate progressively 8. Nutritional labelling: get regional system organised9. Work site and other areas: new plans for physical activity for

the entire community 10. Extensive public education11. Surveillance12. CARICOM: continue development of economic & trade plans

Foci for action in relation to chronic Foci for action in relation to chronic diseasesdiseases

• AlcoholAlcohol• Salt/preservation methodsSalt/preservation methods• Some meats/processedSome meats/processed• Fats- esp. trans Fats- esp. trans • SugarsSugars

• Veg/fruits/cereals Veg/fruits/cereals (whole grain)(whole grain)

• Physical activityPhysical activity

ObesityEnergy Density

Stubbs et al. Am. J. Clin. Nutr. 1995; 62: 316-29.

Effect of covert manipulation of fat content of ad libitum diets on energy balance

0 1 2 3 4 5 6 7-10

-8

-6

-4

-2

0

2

4

6

8

10

12

14

16

18

20

22

24

Time (days)

En

erg

y b

alan

ce (

MJ)

High fat

Medium fat

Low fat

Stubbs et al. Am. J. Clin. Nutr. 1995; 62: 316-29.

Effect of covert manipulation of fat content of ad libitum diets on energy balance

0 1 2 3 4 5 6 7-10

-8

-6

-4

-2

0

2

4

6

8

10

12

14

16

18

20

22

24

Time (days)

En

erg

y b

alan

ce (

MJ)

High fat

Medium fat

Low fat

GDS_0311846_TrofimukA_v7 34

2.5

1.5

0.5

-0.5

-1.5

-2.5

The importance of the non-fat componentThe importance of the non-fat componentSugar-rich beverages increase body weightSugar-rich beverages increase body weight

Raben et al. Am J Clin Nutr 2002; 76: 721-9

Weeks

Weight changes (kg)

0 2 4 6 8 10

Sweetener

Sucrose

Stubbs et al. Am J Clin Nutr, 1995; 62: 316-329

Catering challenges: increases in hidden fat and sugary Catering challenges: increases in hidden fat and sugary drinks evade appetite regulation and lead to weight gaindrinks evade appetite regulation and lead to weight gain

Raben et al., Am J Clin Nutr 2002; 76: 721-9

Sucrose

Sweetener

Weight changes (kg)

Three groups offered the same food but with very different

amounts of fat show that the groups ate the same volume of food so those on high fat foods unconsciously stored energy

and gained weight

Those adults drinking sucrose containing soft drinks gained weight progressively for 10 weeks; those on calorie free drinks lost weight

e.g. Focus on Health Education –but need understandable food labelling; campaigns selectively help upper socio-economic groups

Individual responsibility

Change in the environment

Adapted from Puska P, 2001

• Nutritional standards for food in all government facilities/schools; involve business/catering in Finnish scale fruit + veg. within meal costs

• Selectively increase costs of high fat/sugary products; soft drinks

• Social/medical policies for breast feeding as the norm

• Limit/abolish all marketing to children

• Progressively adapt all towns/cities to favour pedestrian/cycling as norm with car restrictions

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

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

%

OBESEor withchronic disease

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 obesityand chronic diseases: NGOs/academics influence most sectors

NATIONAL/ REGIONAL

Education

Food & Nutrition

Urbanization

Health

Social security

Transport

Media &Culture

Nationalperspective

INTERNATIONALFACTORS

Development

Globalizationof

markets

Media programs

& advertising

Levels of Levels of prevention prevention measuresmeasures

Levels of Levels of prevention prevention measuresmeasures

Targeted prevention

(directed at those with existing

weight problems)

Obesity Report, WHO 2000.

Social initiatives: who to Social initiatives: who to focus on?focus on?

• Different age groups:Different age groups: elderly, middle aged, elderly, middle aged, school children, babies, pregnant women, young school children, babies, pregnant women, young adultsadults

• Different settings:Different settings: – Public sector facilities - hospitals, armed forces, police, Public sector facilities - hospitals, armed forces, police,

schools, nurseries, prisons, old people's homes schools, nurseries, prisons, old people's homes – Private business workplacesPrivate business workplaces– Sports centres,Sports centres,– SchoolsSchools– NurseriesNurseries– Clubs: women's, farmers', arts Clubs: women's, farmers', arts

Social initiatives: who to focus on?Social initiatives: who to focus on?Middle aged & elderly because:Middle aged & elderly because:

• They have the highest incidence of chronic disease

• They show the greatest benefit from interventions on diet and physical activity

• They are the neglected groups as the focus is usually on children

• The elderly have a major opportunity to contribute to both their own wellbeing and that of their grandchildren

• Can be shown to learn completely new skills

• Are often highly motivated

Examples of benefits for older people of Examples of benefits for older people of diet and exercise changesdiet and exercise changes

• Risk of cardiovascular diseaseRisk of cardiovascular disease - both coronary artery - both coronary artery disease and strokes - highly dependent on risk disease and strokes - highly dependent on risk factors with proven benefits from reversal. New risk factors with proven benefits from reversal. New risk charts suggest benefit from simple screening which charts suggest benefit from simple screening which all doctors can do very quickly and which individuals all doctors can do very quickly and which individuals can understandcan understand

• DiabetesDiabetes maximum incidence rate in >50s with maximum incidence rate in >50s with maximum marked proven reduction in the maximum marked proven reduction in the development in diabetes from defined changes in development in diabetes from defined changes in both diet and physical activity.both diet and physical activity.

• Nutritional qualityNutritional quality of diet critical because total energy of diet critical because total energy intake lower so avoidance of anaemia and vitamin intake lower so avoidance of anaemia and vitamin deficiencies provide major benefits including mental deficiencies provide major benefits including mental function. function.

Elderly: few know the extent of their vulnerability & Elderly: few know the extent of their vulnerability & the benefits of interventionthe benefits of intervention

Gaziano et al. Lancet 2008;371:923-931

No DiabetesNon - Smoker Smoker SmokerNon -Smoker

Diabetes

% Reduction in the incidence of type 2 % Reduction in the incidence of type 2 diabetes vs. control (diabetes vs. control (± confidence limits)± confidence limits)

US Diabetes Prevention ProgramUS Diabetes Prevention Program

Age (yrs)Age (yrs) MetforminMetformin Diet and exerciseDiet and exercise

OverallOverall 31 (17-43)31 (17-43) 58 ( 48 -66)58 ( 48 -66)

25-4425-44 44 (21-60)44 (21-60) 4848 (27 -63) (27 -63)

45-5945-59 31 (10 -46)31 (10 -46) 5959 (44-70) (44-70)

≥≥6060 11 (-33 - 41)11 (-33 - 41) 7171 (51-83)(51-83)

DPP study. NEJMed. 2002; 346:393-403

The great benefit of diet and exercise for preventing The great benefit of diet and exercise for preventing the onset of type 2 diabetes in the elderlythe onset of type 2 diabetes in the elderly

WHERE IS THE PRIORITY ?WHERE IS THE PRIORITY ?

-2

1.0

2.0

3.0

4.0

5.0

1 2 3 5

Birth weight (kg)

Relative risk of adult disease

4

Adult Adult metabolic metabolic syndromesyndrome

Childhood Childhood obesityobesity

Optimum birth weights in relation to adult risk of diabetes, Optimum birth weights in relation to adult risk of diabetes, cardiovascular disease & cancer: depends crucially on cardiovascular disease & cancer: depends crucially on

non-smoking, good nutrition in pregnancynon-smoking, good nutrition in pregnancy

Mobilising society: focus on the most committed; Mobilising society: focus on the most committed;

then the most powerful & effective groupsthen the most powerful & effective groups

• Societal groupsSocietal groups: Women's organisations, business : Women's organisations, business men's clubs, trade unions men's clubs, trade unions

• NGOsNGOs - consumer groups - consumer groups

• AcademicAcademic: medical, nurses, nutritional, dietetic, : medical, nurses, nutritional, dietetic, sports/physiotherapy, social science and economics sports/physiotherapy, social science and economics

• Professional groupsProfessional groups: architects, urban planners, : architects, urban planners, environmentalists, transport experts environmentalists, transport experts

• Food chainFood chain: Farming, manufacturing, catering & : Farming, manufacturing, catering & trade organisations, food writers, TV cookstrade organisations, food writers, TV cooks

• ClubsClubs e.g. walkers, cyclists, swimmers, dance e.g. walkers, cyclists, swimmers, dance groupsgroups

Strategies for engagement and promoting Strategies for engagement and promoting prevention initiativesprevention initiatives

• Involve key groupsInvolve key groups in developing not just in developing not just implementing the planimplementing the plan

• Need a national bodyNeed a national body to drive public/private to drive public/private involvement involvement

• Public transparencyPublic transparency the key: rarely do the key: rarely do government initiatives of a cross sectoral nature government initiatives of a cross sectoral nature work if the organisation remains within government; work if the organisation remains within government; only exceptions are national security or crisis only exceptions are national security or crisis managementmanagement

• Set public goalsSet public goals which require societal and which require societal and individual changes individual changes

• MediaMedia: involve the best and accept bad publicity is : involve the best and accept bad publicity is often a useful stimulus in the long termoften a useful stimulus in the long term

WHO/PAHO

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

Government policies need to support the public and private sectors in their promotion of chronic disease prevention through a National Public Institution

Challenges for the Medical Profession - 1Challenges for the Medical Profession - 1

a) Assess practices publicly on a regular basis

b) Payment for effective treatment : striking difference between the poor response of European Cardiologists in their usual practice and UK GPs' success when paid if >80% of their patients are under proper hypertensive control

c) Coherent public support demanded: medical profession needs to be challenged to support local and national preventive initiatives

Improve screening procedures and effective Improve screening procedures and effective treatment: evidence shows doctors respond treatment: evidence shows doctors respond best when:best when:

Challenges for the Medical Profession - 2 Challenges for the Medical Profession - 2 Primary care physiciansPrimary care physicians

• GPs need to develop a coherent strategy of opportunistic screening and audit of their practice / community as proposed by Scottish SIGN guidelines for obesity (see next 2 slides)

• Link with exercise facilities and local government initiatives for physical activity

• Play major new role in pregnancy care: public scrutiny of the % success of breast feeding rates of patients

• Take new approaches to reorganise their practices with nurse - or non - professional voluntary groups for obesity management

• Identify those vulnerable to illness

Assess current disease and risk factors

Smoking, excess alcohol, lipids, blood pressure

Offer weight management

high risk

1. RECRUITMENT & REFERRAL

Self-referral

Practice audit

Opportunistic screening

>30

25-30 <25

Measure BMI

low risk

Accepts

Patient refuses

2. BMI ASSESSMENT

3. PATIENT CRITERIA

4. HEALTH ASSESSMENT

6. WEIGHT MANAGEMENT

5. RISK FACTOR MANAGEMENT

Waist measurementRisk factors, e.g. smokingBlood pressureUrine glucose

Plasma -glutamyl transferaseTotal plasma cholesterolThyroid stimulating hormone

Scotland's Physicians' Colleges SIGN Scotland's Physicians' Colleges SIGN Obesity Guideline No 8, 1995Obesity Guideline No 8, 1995

Unsuccessful outcome

Successful outcome, e.g.

>5 kg loss

Healthy eating advice

Maintenance of weight loss achieved. Regular monitoring.

Prevention of further weight gain

Consider additional drug therapy if BMI >30

Drug therapy continues

Consider specialist referral for surgery if BMI >35 with major

risk factors

Unsuccessful outcome

Offer weight management

Accepts

Patient refuses6. WEIGHT MANAGEMENT

3-month weight loss programme, including:

ExerciseBehavioural adviceDiet

Support scheme:FamilyHealth CentreCommunity

Scotland's College of Physicians SIGN Guideline No 8, 1995Scotland's College of Physicians SIGN Guideline No 8, 1995

Requires a reorganisation of primary health care practices

An integrated comprehensive model for school-An integrated comprehensive model for school-based obesity/chronic disease prevention.based obesity/chronic disease 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

Strategies for combating childhood obesity: a Strategies for combating childhood obesity: a challenge for consumerschallenge for consumers

Protecting children aged up to 18 yrs:Protecting children aged up to 18 yrs: Breast feedingBreast feeding Proper weaning practicesProper weaning practices Regulated child minders: food and playRegulated child minders: food and play Legislate on all forms of marketing: TV, radio, Legislate on all forms of marketing: TV, radio,

text messages, internet, food product text messages, internet, food product labelling, games etc. labelling, games etc.

School environment:School environment: Supermarket practicesSupermarket practices Pricing policies : affect school aged childrenPricing policies : affect school aged children Availability policies : density of fast foods Availability policies : density of fast foods

outlets outlets

Strategies for childhood obesity: School councils Strategies for childhood obesity: School councils with parental/ pupil/teacher/governors needed with parental/ pupil/teacher/governors needed

School environmentSchool environment:: No "choice" !No "choice" ! No vending machines No vending machines Activities and sports for all: after school activities Activities and sports for all: after school activities Defined high quality meals onlyDefined high quality meals only Contracts with parents on foodContracts with parents on food Food and activity committee with Governor, pupil,Food and activity committee with Governor, pupil,

parental representation parental representation Nutrition educationNutrition education Walk/bike to school: changing and storage facilitiesWalk/bike to school: changing and storage facilities Traffic policies around schoolTraffic policies around school Parental policies on transport to schoolParental policies on transport to school

Fundamental changes in physical activity: Fundamental changes in physical activity: inevitable and optional changesinevitable and optional changes

Inevitable: Rural to urban transition Labour changes; Mechanisation/computerisation of standard work; also home

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 for safety

e.g. for older people Park/leisure/sports facilities/school PA lessons Ease of transport of perishable foods into towns/cities

Roads within 500m

Roads further than 500m

Railways

Canals & streams

Shops*

Town planning crucial: in one UK town only a few roads are within 500 m of one or more shops where food is reasonably priced & selling >8 kinds of fresh fruit and vegetables; other roads require motor transport to shops

Source: Dowler, Blair et al 2001

Options for transport to work: the fundamental Options for transport to work: the fundamental importance of physical exerciseimportance of physical exercise

• Energy imbalance if adults gain on average 0.5kg per Energy imbalance if adults gain on average 0.5kg per year year ≈ imbalance 3,500kcal ≈ imbalance 3,500kcal ≈ 10 kcal/d≈ 10 kcal/d

• Travel to work cyclingTravel to work cycling for 1 for 1 hourhour each wayeach way = 480 kcal= 480 kcal

• Travel to work by busTravel to work by bus assuming each journey 50minassuming each journey 50min Total cost = 316 Total cost = 316

kcalkcal

• Travel by carTravel by car for 30min for 30min Total cost = 201 kcalTotal cost = 201 kcalConclusions: policies favouring car use induce average

population fall in energy needs of 140-280 kcal/d Cycling/walking to work automatically uses about

150kcals/day more than public transport

Sarah Hinde: The car-reliant environment. In: The 7 deadly sins of obesity. Univ. of NSW, Australia. 2007.

CAR-RELIANCE limits child development

Increase in traffic

Parent concern for child safety

Sedentary replaces active

transport

Parents chauffeur children

Organised sport replaces play for

children

PHYSICAL INACTIVITY

Declining activity: age effects and recent Declining activity: age effects and recent trends in childrentrends in children

UK National Survey of adults

US National Survey of children 5-15 yrs.

% children walking to school

Adults achieving suggested 30 mins walking x 5 / wk

Marvellous opportunities for activity in the Netherlands

Few extracurricular sports in English Few extracurricular sports in English children aged 7-11 years at primary school children aged 7-11 years at primary school

% participating in the year

BoysBoys GirlsGirls

Aerobics, keep fitAerobics, keep fit 4040 5454

Other games skillsOther games skills 7474 7979

Sports, e.g.Sports, e.g.

FootballFootball 2020 33

NetballNetball 11 1111

No extracurricular sportsNo extracurricular sports 6969 6969

Taken from Mason, 1995. Young people and Sport in England, 1994. A National Survey

Prevalence of obesity in schoolchildren in Singapore - Prevalence of obesity in schoolchildren in Singapore - immediate impact from huge effort led by Prime Minister: immediate impact from huge effort led by Prime Minister: now abandoned because focus on selective controls for now abandoned because focus on selective controls for

overweight children became socially & politically sensitiveoverweight children became socially & politically sensitive%

16

14

12

10

8

6

4

2

19

7

6 19

7

8 19

8

0

19

8

2 19

8

4 19

8

6 19

8

8 19

9

0 19

9

2 19

9

4 19

9

6 19

9

8 20

0

0

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

The most cost-effective community (not national) The most cost-effective community (not national) interventions for Australian childreninterventions for Australian children

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

Obesity: time watching TV overwhelms leisure activity in Obesity: time watching TV overwhelms leisure activity in Australia: community activities as a substitute crucial for Australia: community activities as a substitute crucial for

both physical, mental and societal healthboth physical, mental and societal health

Adapted from Salmon, Bauman et al. IJO 2000;Adapted from Salmon, Bauman et al. IJO 2000; 24:600-60624:600-606

21

22

23

24

25

26

27

28

*High *Mod #Low Inactive

<1 hr/day

1-2.5 hrs/day

2.5-4 hrs/day

>4 hrs/day

TV time

Increasing TV timeLeisure time

sport & activity

Average BMI for

each group

28

27

26

25

24

23

22

21

Total daily physical activity

High Moderate Low Inactive

Potential mechanisms for combating distorted Potential mechanisms for combating distorted urban environments urban environments

Urban planningUrban planning crucial to: crucial to:

a)a) Minimise Minimise car usecar use; encourage public transport, cycling and ; encourage public transport, cycling and pedestrian habits, e.g. London - congestion charging; pedestrian habits, e.g. London - congestion charging; Copenhagen, Netherlands Copenhagen, Netherlands

b)b) Community & sports facilitiesCommunity & sports facilities in grouped flats e.g. in grouped flats e.g. Singapore Singapore

c)c) School facilitySchool facility policies and environment - e.g. road policies and environment - e.g. road systemssystems

d)d) Supermarket / shopping mallSupermarket / shopping mall location policies (UK) location policies (UK)

e)e) Housing estate lay-outHousing estate lay-out - a crucial determinant of transport - a crucial determinant of transport choices (US)choices (US)

f)f) Urban storage:Urban storage: refrigeration facilities and transport lines refrigeration facilities and transport lines for rural products e.g. fruit, vegetables for rural products e.g. fruit, vegetables

g)g) Fast food outlets: Fast food outlets: control urban densitycontrol urban density

Approaches to reinforcing individual responsibilitiesApproaches to reinforcing individual responsibilities

• Choosing suitable foods: demands understandable food labelling : new concept of nutritional profiling crucial for food labelling to allow individuals to change

Some UK health centres have weekly posters of best & cheapest foods in local supermarkets

Local councils transfer fruit/vegetables into urban slums and create new facilities

• Physical activity: try pedometers; community facilities for a variety of sports/leisure e.g. dancing

Some UK health centres organise with local council special walks/outdoor exercises x3 per week for groups

• Individuals at risk: can identify themselves of developing diabetes, e.g. a) high waist circumference, b) over 40 yrs c) diabetes in family: intervention provide clear benefit

18%

59%7%

8%7%

0

2

4

6

8

10G

ram

s / 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

10G

ram

s / d

ay

Non-salt food additives

Natural

Cooking

Water and Medicines (1%)

Table

Added salt

Salt sources in a Western diet dominated by salt in purchased foods: good food labelling crucial

Derived by the lithium technique: James et al., Lancet,1987; 1: 426-429. Edwards et al. Eur J Clin Nutr 1989 43:855-61

**

*

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

Testing consumer responses: % incorrect responses in all those who made use of the signposting system

Conclusions: using signposting produces significantly lower levels of incorrect responses with Multiple Traffic Light system and nutritional profiling of GDA scheme.

Incorrect response

Simple Traffic

Multiple Traffic

Colour GDA

Mono GDA

Across all age, geographic, socio-economic and main ethnicity groups

No Signposting

62%

58%

31%

10%

69%

Consumer purchases in response to traffic light food Consumer purchases in response to traffic light food labelling of principal nutrients as in healthy (green), labelling of principal nutrients as in healthy (green),

reasonable (yellow), or unhealthy (red) amounts.reasonable (yellow), or unhealthy (red) amounts.

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)

Sainsbury's Supermarket presentation to The National Heart

Forum, UK., 2006.

'Taste the Difference' Melting Middle Chocolate

puddings4 red, 1 amber

'Be Good to Yourself' Chocolate sponge

puddings4 Green, 1 amber

42%

89%

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

• 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

ConclusionsConclusions• Greater societal challengeGreater societal challenge with obesity &cancer than with obesity &cancer 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 obesogenic environmentToxic obesogenic environment needs major changes. To needs major changes. To improve society's obesity levels need big external changes in improve society's obesity levels need big external changes in food and activity opportunities to overcome biological food and activity opportunities to overcome biological buffering by appetite control mechanism buffering by appetite control mechanism

• 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 be helpedIndustry can be helped by developing specified regulations by developing specified regulations set out over 5 years and with projected changes to allow set out over 5 years and with projected changes to allow innovation.innovation.

• External public health groups/bodyExternal public health groups/body: drive change, report to : drive change, report to Parliament; publicly transparent: great help to Ministries of Parliament; publicly transparent: great help to Ministries of Health in driving political change Health in driving political change

• Medical leadersMedical leaders should start working for the public Interest! should start working for the public Interest!