Resist the “Snack Attack”
Carlos A. Monteiro warns of the dangers of ultra-processed foods, noting that our personal and social well-being is at risk.
In spite of progress being made in the field of undernourishment, a new trend in malnutrition is on the rise in the Global North and South: obesity.
It is a double-edge sword: Malnutrition is not only associated with undernutrition – it includes also overweight and obesity. Both phenomena frequently occur in combination with micronutrient deficiencies. Half of the world’s countries still struggle with the serious multiple burdens of malnutrition. While some countries have made tremendous progress combating undernutrition, obesity and overweight are on the rise. This poses serious risks to health, since obesity and overweight reduce life expectancy and are major risk factors for non-communicable diseases, such as type 2 diabetes, and cardiovascular diseases, such as myocardial infarction and ischemic stroke.
The problem of malnutrition facing the world is huge. According to global estimates from 2013, 161 million children under the age of five are stunted (too short for their age) and at least 51 million are severely or moderately wasted (weigh too little for their height). At the same time, an additional 42 million children are overweight by the age of five. Across all age groups, an estimated 2.1 billion people were overweight in 2014. Worldwide, 39% of adults have a body mass index of 25 kg/m2 or higher. There are also over two billion children and adults who are deficient in one or more vitamins or minerals.
…overweight and obesity are increasing everywhere, and the number of children and adolescents affected is especially alarming.
A look at recent trends shows that stunting is on the decrease. In 2013, 25% of all under-five-year-olds were stunted down from 33% in 2000. In low income countries, stunting of children under five is still one of the biggest problems. About half of all stunted children live in Asia and over one third in Africa. At the same time, overweight and obesity are increasing everywhere, and the number of children and adolescents affected is especially alarming. If current trends continue, the occurrence of overweight of children under age five will rise to 11% worldwide by 2025 with very rapid increases in low- and lower-middle-income countries, especially in Africa and Asia. Between 2000 and 2013, the prevalence of childhood overweight increased from 11% to 19% in some countries in southern Africa and from 3% to 7% in South-East Asia (UN region). The steady increase in childhood overweight reinforces the overweight and obesity epidemic in adulthood and is increasingly creating health challenges for the next generation.
Poor nutrition und undernutrition during early life increases the risk of overweight, obesity and diet-related diseases in later life.
Overweight and obesity are strongly linked to maternal nutrition and health and nutritional status in early life. When looking at the intergenerational influence, we see that a mother’s nutritional status prior to conception and her diet during pregnancy have a major influence on foetal growth and development. Poor nutrition und undernutrition during early life increases the risk of overweight, obesity and diet-related diseases in later life. The well-being of adolescent girls and young women is therefore especially important, as their health can affect the well-being of future generations. Obese mothers are more likely to have obese children as well. This is a vicious cycle that involves all age groups. There is increasingly persuasive evidence that breastfeeding protects children against obesity. It is important that relevant public health measures are taken at each stage of the life cycle.
In addition to the consequences for the health of individuals, malnutrition also effects the economic development and stability of a society’s health system. National productivity losses can be as high as 3% of total output per year. The burden of the diseases associated with overweight and obesity present a huge challenge to health systems, especially in countries without the means for dealing with the increase in patients who might need lifelong treatment. This imposes an economic burden on society through increased medical costs added to the lost economic productivity due to absenteeism and premature death. We would like to describe two examples that illustrate how malnutrition has been evolving: one from Europe - typical for high income countries - and one from Latin America - an example from a world region that has experienced rapid socio-economic growth and food system changes.
Many of the obesity-related health conditions once thought to apply only to adults are now being increasingly found among children.
Overweight and obesity are a serious public health challenge in Europe, where their prevalence is rising rapidly. They are responsible for about 80% of cases of type 2 diabetes, 35% of ischemic heart disease, and 55% of hypertensive disease among adults, and cause more than 1 million premature deaths and 12 million life-years of ill health each year. Obesity is responsible for up to 6% of national health care costs. It affects the poor in Europe more severely, imposes a larger disease burden on them, and limits their opportunities for improving their socioeconomic status. Many of the obesity-related health conditions once thought to apply only to adults are now being increasingly found among children.
Latin America has experienced significant, though uneven, economic growth in the past decades. Inequalities have been reduced and extreme poverty was cut by half mainly due to rising income from employment and other sources. Overall there has been great progress in reducing stunting levels by half from 25% to 12% between 1990 and 2013. However, the rising levels of overweight and obesity and the diseases associated with them constitute a major public health concern across the region. In Brazil, the decrease in the prevalence of stunting in children under five from 20% to 7% between 1989 and 2006 has been accompanied by a steady increase in the prevalence of overweight and obesity. The occurrence of overweight adult and adolescent males increased from 30% to 50% and that of females from 41% to 48% during the same period. In Mexico around 14% of children under five are currently stunted and 9% are overweight or obese. 65% of adult women are overweight or obese.
The modern food environment offers an endless range of opportunities to consume food and drink products.
What are the underlying reasons for overweight and obesity? It is widely recognized that socioeconomic and environmental changes have an impact on dietary and physical activity patterns. They can lead to higher susceptibility to obesity through increasingly sedentary lifestyles and consumption of food that is high in fat, especially saturated and trans-fats, sugars, and salt/sodium. Rapid urbanization and changing lifestyles together with the increased production and marketing of processed food have led to a shift in dietary patterns. The modern food environment offers an endless range of opportunities to consume food and drink products. This inadvertently leads to what has been described as “passive overconsumption”, where the individual has no way of recognizing that he or she is consuming particularly energy-dense products. Two dietary factors are particularly conducive to overeating: the consumption of very energy-dense foods that contain extra fat and/or sugars, and the consumption of energy-rich, sugary drinks between meals. Current food systems are being increasingly challenged to provide safe, diversified and nutrient-rich foods. These challenges are posed by both unsustainable production and unsustainable consumption patterns alike.
The good news is that it is possible to reverse this rising trend and bring the overweight and obesity epidemic under control. This requires comprehensive action, since the root of the problem lies in the rapidly changing social, economic and environmental determinants of people’s lifestyles. Determinants of obesity and of obesity-causing environments involve a broad range of sectors and result from policies in agriculture, trade, education and planning, as much as in health and social welfare.
To solve the persistent problems of malnutrition, the FAO and WHO jointly organized the Second International Conference on Nutrition (ICN2) in Rome in 2014, where world leaders and high-ranking national advocates committed to improving nutrition in their countries and globally. The ICN2 agreed on a series of necessary actions that are outlined in the ‘Framework of Action’. Countries can choose the option best suited for addressing the double burden of malnutrition in their specific context. Many of the ICN2 recommendations focus on the need for global change in redesigning our food systems to meet the nutritional needs of people. This implies government-led policies and regulations on the side of both food supply and demand and covers a broad range of sectors.
Agricultural production and other aspects of the supply chain should be coordinated with public health objectives.
Efforts to combat undernutrition must continue, of course, and we are well aware of what needs to be done. At the same time, efforts have to be undertaken to halt and reverse the rising overweight and obesity pandemic. A healthy diet and growth strategy is needed for children and adolescents that protects them from malnutrition in all its forms. Action to promote a healthier food supply starts with food production. The ICN2 Framework for Action recommends integrating nutritional objectives into food and agriculture policies. Agricultural policy influences dietary patterns through the relative pricing and availability of different types of food. For decades, policies have been geared towards producing ever cheaper fats, sugars and animal products. Countering their negative effects is currently a major policy challenge. Agricultural production and other aspects of the supply chain should be coordinated with public health objectives. This includes revising the current European policy of incentives for sugar and fat production, for example, and rethinking tariffs that restrict trade in fruit and vegetables. Sustainable local production should also be encouraged.
The omnipresent commercial promotion of food and non-alcoholic beverages to children needs to be regulated.
The omnipresent commercial promotion of food and non-alcoholic beverages to children needs to be regulated. Marketing food and beverages to children is a major concern, and not only in Europe. Some countries have introduced legislative regulations that ban this form of advertisement, while others have imposed voluntary guidelines or made health warnings mandatory in processed food and drink advertising.
The ICN2 Framework for Action addresses the importance of breastfeeding and recommends a set of actions to promote, protect and support breastfeeding. This could be accomplished by maintaining and expanding baby-friendly hospitals, enforcing the International Code of Marketing of Breast-milk Substitutes, and developing labour policies for women that allow sufficiently long maternity leave and support in the workplace. Guidelines for infant feeding should be provided in addition to training and support for parents.
In response to consumer demand, there is an ongoing trend towards improved information and easily understandable labels.
Another important step would be to explore possible regulatory and voluntary instruments to promote healthy diets. These include informative nutritional labelling on products. In response to consumer demand, there is an ongoing trend towards improved information and easily understandable labels. Sweden’s keyhole symbol on food labels and the United Kingdom’s traffic light system are some examples. Other countries already use or are considering adopting fiscal measures, such as taxing unhealthy foods and providing incentives to encourage the supply and consumption of healthy foods. Norway has specifically suggested lowering the prices of fruits and vegetables and subsidizing their distribution to remote areas, as well as raising taxes on energy-dense and nutrient-poor foods. In Switzerland, a proposal for the taxation of energy-dense foods was recently introduced and is awaiting implementation.
Mexico’s response to the double burden of malnutrition has been two-fold, with targeted social protection measures on the one hand and regulatory instruments to promote a healthy diet on the other. The country has implemented a social protection programme for poor rural households in remote areas, offering assistance in the form of a cash transfer or a basket of food of equivalent value each month. At the same time, the government recently started addressing the rising consumption of ultra-processed, energy-dense foods and sugar-sweetened beverages by introducing taxes on both.
Ultimately accountability is important and needs to be strengthened across all actors. The ICN2 Framework for Action addresses accountability and encourages national governments to establish nutrition targets and intermediate milestones, including agreed international indicators (like the six World Health Assembly global nutrition targets and the nutrition-related targets of the Global Action Plan for the Prevention and Control of NCDs 2013-2020) as part of their national monitoring frameworks. This also includes the monitoring of the nutrition policy environment and its actors. More needs to be done to hold the food industry to account for improving the healthfulness of our food environments.