NUTRITION IN OBESITY AND NCD CONTROL

- THE ROLE OF CIVIL SOCIETY

FITZROY HENRY

CFNI(PAHO/WHO)

HEALTHY CARIBBEAN CONFERENCEBarbados

October, 2008

OUTLINE OF PRESENTATION

• WHAT IS THE NUTRITION GOAL?

• WHAT ARE THE GLOBAL & LOCAL CHALLENGES FOR CIVIL SOCIETY?

• WHAT IS THE STRATEGIC APPROACH?

• SOME KEY ROLES FOR CIVIL SOCIETY TO ADVANCE THIS STRATEGY?

0

10

20

30

40

50

60

(%

)

1970s 1980s 1990s

Male

Female

OVERWEIGHT/OBESITY TRENDSIN THE CARIBBEAN

The Prevalence of Obesity (BMI ≥30) Hypertension and

Diabetes in Caribbean Countries

0

5

10

15

20

25

30

35P

erce

nt

%

Belize

Jamaica

Guyana

St Kitts

/Nevis

Trinidad/Tobago

Obesity

Hypertension

Diabetes

Trends in Fat Consumption in the Caribbean1961-2003

0

100

200

300

400

500

600

700

800

1961-63 1971-73 1981-83 1991-93 2001-2003

Calo

ries/c

aput

/day

Imported

Local

GOAL

Trends in Sugar Consumption in the Caribbean1961-2003

0

50

100

150

200

250

300

350

400

450

500

1961-63 1971-73 1981-83 1991-93 2001-2003

Calo

ries/c

aput

/day

Local Imported GOAL

Trends in Fruit and Vegetable Consumption in the Caribbean1961-2003

0

50

100

150

200

250

300

350

400

1961-63 1971-73 1981-83 1991-93 2001-2003

calor

ies/ca

put/d

ay

Local Imported Goal

THE GOAL

•Fats

•Sugars

•Fruits and Vegetables

Energy (Caloric) Availability in the Caribbean 1961-2003

1500

1700

1900

2100

2300

2500

2700

2900

19961-63 1971-73 1981-83 1991-93 2001-2003

Calo

ries/c

aput

/day Average Energy supply

RDA

Average caloric availability is increasing globally

2,000

2,200

2,400

2,600

2,800

3,000

3,200

3,400

1965 1975 1985 1998 2015 2030year

per

capi

ta e

nerg

y su

pply

Africa South ofSahara

South Asia

Latin America& Caribbean

Near East and NAfrica

East Asia

World

Source: FAOSTATSource: FAOSTAT

Effect of rising national income on composition of the diet

(Perisse, Sizaret & Francois, 1969)

Can Civil Society impact Global Forces, National Policies & Individual Choice?

•Fats

•Sugars

•Fruits and Vegetables

Where can Civil Society best Influence Nutrition

MACRO LEVEL (National/International)

WTO, EPA, CET Agreements- Alters Food availability,Type & Prices. Etc

MESO LEVEL (Public & Private sectors)

Aggressive Food MarketingQuality Standards, LabelingDietary Guidelinesetc.

MINI LEVEL(Community/Household)

Food Access: More food at lower cost Media influence etc.

MICRO LEVEL(Individual)

No. & Type of dietPassive over-consumptionetc.

Can Civil Society Influence the Major Factors Affecting Food Choices in the

Caribbean?

1. TASTE

2. COST

3. CONVENIENCE

4. NUTRITION/HEALTH VALUE

5. TRADITION / CULTURE

CAN CIVIL SOCIETY ACTION IMPACT ON KEY DRIVERS OF

OBESITY/NCDs?…..• Our domestic agriculture policy lacks

adequate incentives for the production of fruits and vegetables

• Our local and cable networks heavily advertise fast foods, especially on children’s programs

• Many schools canteens and vendors promote high energy dense foods with little nutrient value

• Our food imports encourage the consumption of high energy dense foods, even trans fats

Changes Diet Composition

4.6

11.1

22.2

3.35

12.5

28.5

3.4

11.514.5

45.4

8.7

17.8 18.9

39

15

0

10

20

30

40

50

China India Malaysia Thailand

Gra

ms

per

capi

ta p

er d

ay 1965 1975

1985 1995

Increased Vegetable Oil Consumption is key component of

nutrition transition in Asia

Source: Food Balance data, FAO

0

5

10

15

20

25

30

Grams/person/

day

Trends in Vegetable Oil and Animal Fat Consumption in the Caribbean

Vegetable Oil

Animal Fat

100

80

60

40

20

0

-20

-40

1%E 2%E 3%E 4%E 5%E

Trans

Sat

Mono

Poly

% C

han

ge in

CH

D

Dietary Intake (% Change in Energy)

Among 80,082 women followed for 14 years (939 cases). Multivariate-adjusted for other risk factors and dietary habits. Hu et al. NEJM 1997

0.6

0.8

1

1.2

1.4

Q1 Q2 Q3 Q4 Q5

Saturated Fat

Mono

Poly

Trans

Multivariate RR’s of type 2 diabetes according to quintiles of Multivariate RR’s of type 2 diabetes according to quintiles of specific types of dietary fat (mutually adjusted)specific types of dietary fat (mutually adjusted)

(Salmeron et al, 1999)

Quintiles of Fat Intake

Mu

ltiv

aria

te R

R

25.004

Who would make it?

CIVIL SOCIETY ACTION

ON DIET & NCDs- 3 Critical Questions

• CAN SPECIFIC NUTRIENTS (e.g. SUGAR, FAT, SALT)BE TARGETED SUCCESSFULLY?

• CAN THIS APPROACH MAKE A SIGNIFICANT DIFFERENCE?

• WHAT ARE THE SUCCESS FACTORS?

Changes in dietary consumption in Norway Changes in dietary consumption in Norway (1970 – 1993)(1970 – 1993)

(Norwegian Nutrition Council, 1995)(Norwegian Nutrition Council, 1995)1970 1993

Energy (kcal) 2860 2980

Fat (g) 128 112

Fat (%) 40 34

Carbohydrate (g) 352 392

Carbohydrate (%) 49 53

Of which sugars (%) 16 17

Coronary Heart Disease mortality in Norway

Norwegian National Bureau of Statistics

Total TFA content in the soybean oil, Costa Rica 1995-2004

0

5

10

15

20

25

1995-96 2000-01 2002 2003 2004

To

tal

TF

A i

n s

oyb

ean

oil

(%

)

(Baylin A, et al. .JFCA.2006)

Adipose tissue TFA among soybean oil consumers

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Before 2000 2000 2001 2002 2003

Ad

ipo

se ti

ssu

e (

g/1

00g

)

Total trans-fatty acid among soybean oil users, Total trans-fatty acid among non-soybean oil users,

P-test for trend p<0.001

(Colón-Ramos U, et al. J Nut, 2006)

Other Intervention studies(some of the nearly 50-100 projects in

the literature) Stanford Three-Community study (USA) Stanford Five-City project (USA) Minnesota Heart Health Program (USA) German Cardiovascular Prevention study Kilkenny Health Project (Ireland)

Mirame project in Chile Tianjin Project in China Mauritius –WHO Inter-Health (1987-

1992)

Experience from FinlandExperience from Finland(North Karelia Project 1972 -(North Karelia Project 1972 -

1992)1992)Important aspects of the

successful public policy:

Inter-sectoral collaboration Presence of a responsible agency –

national focal point Nutrition education programmes Support for voluntary organisations Food labelling and food pricing policies Research and demonstration International collaboration

PUBLICFOOD

ACTION POINTS TO COMBAT OBESITY

NATIONALMULTI-SECTOR

COMMUNITY/CIVIL SOCIETY

FOOD POLICY

AGRICULTURE/IMPORTED FOOD

HEALTH POLICY

EDUCATIONPOLICY

LABOUR/TRANSPORT

POLICY

FOOD INTAKE:NUTRIENT DENSITY ENERGY EXPENDITURE

LEISUREACTIVITY

FACILITIES

WORKSITEEXERCISE

SCHOOLEXERCISE

WORKSITEFOOD

SCHOOLFOOD

OBESITY

CIVIL SOCIETY INSTITUTIONS CAN MAKE A BIG DIFFERENCE viz….

SUSTAIN MEDIA CAMPAIGNS

USE TALK SHOWS ETC. TO INFORM PUBLIC

ON DANGERS OF SAT FATS, TRANS FAT,

EXCESS SUGAR, SALT, ETC.

PROTEST UNACCEPTABLE

NUTRITION POLICIES/PRACTICES

BYPUBLIC SECTOR

ORPRIVATE SECTOR

FORCE LEGISLATIVE CHANGES

REQUIRE CAL & FAT INFO ON MARKETED FOODS

- LABELING STANDARDS- USE DIETARY GUIDELINES

DEMAND HEALTHY MEALS

THROUGH PTAs, CORPORATE BOARDS,

AND COMMUNITY COMMITTEES- PUSH FOR HEALTHY DIETS

IN SCHOOL/WORKSITE CANTEENS & VENDORS

ADVOCATE FOR FISCAL CHANGE

DISINCENTIVES FOR OBESOGENIC FOODS

SUBSIDIES FOR LOCALNUTRITIOUS FOODS

INCENTIVES FOR DIET/WEIGHT MANAGEMENT PROGRAMS

OPPORTUNITIES FOR CIVIL SOCIETY ACTION IN NUTRITION TO COMBAT

OBESITY/NCDs

PROMOTE HEALTHYFOODS IN COMMUNITY

USE FAITH-BASED, OTHER NGOsTO DEMONSTRATE PREPARATION, USE

AND VALUE OF HEALTHY FOODS

MULTI-SECTOR FOOD & NUTRITION APPROACH MULTI-SECTOR FOOD & NUTRITION APPROACH

Memberstates

Memberstates

Civil SocietyCivil

SocietyPrivate sectorPrivate sector

FAOPAHOCARDI

IICA

FAOPAHOCARDI

IICAPh

ase

II FULLY IMPLEMENT FOOD & NUTRITION ACTIONS FULLY IMPLEMENT FOOD & NUTRITION ACTIONS

NATIONAL PLANSNATIONAL PLANS

CCHCCHCARICOMCARICOMCFNICFNIP

has

e II

I

HOG SUMMIT ON OBESITY & NCDsSEPTEMBER 2007

HOG SUMMIT ON OBESITY & NCDsSEPTEMBER 2007

Ph

ase

I

THANK YOU