Tobacco and obesity epidemics: not so different after all?
http://www.100md.com
《英国医生杂志》
1 School of Public Health, University of the Western Cape, Bellville 7535, Western Cape, South Africa, 2 Institute of Human Nutrition, Columbia University, New York, USA
Correspondence to: M Chopra mchopra@uwc.ac.za
Campaigns to promote healthy eating are undermined by the ubiquity of processed, energy dense foods. A global strategy is now needed to tackle the rising prevalence of obesity
Introduction
In the United States, obesity has risen by 74% in the past decade, with at least one in five adults now classified as obese.5 Similar trends are seen in most Western countries.6 In the Middle East and North Africa, and in much of Eastern Europe and Latin America, levels of overweight and obesity in women are similar to, or exceed, those of the United States.7
Total energy (calories) supplied by food and beverages has increased as food has become more processed and more energy dense. In North America, fat and sugar account for more than half the total dietary energy intake.8 These changing dietary patterns are becoming mirrored in developing countries. For all developing countries combined, the per capita supply of beef, mutton, goat, pork, poultry, eggs, and milk rose by an average of 50% between 1973 and 1996.9 The transition towards a more energy dense diet is also occurring at much lower income levels than previously.10
Obesogenic environment
An important feature of global food systems has been the consolidation of agricultural, food, and retail companies into large transnational corporations. More than half the market in most main foodstuffs in Europe and America is produced by a handful of corporations such as Unilever. The challenge for these corporations is how to continue to make profits when the market for food is so saturated in developed countries (the food supply already contains 15.9 MJ (3800 kcal) for every adult and child in the United States—that is, nearly twice what is needed on a daily basis). The corporations are approaching this in several ways:
By convincing people to consume more, and more highly energy dense, foods through relentless advertising and ubiquity of outlets
By increasing serving size and adding price inducements to order the larger sizes
By opening up markets in transitional and developing countries, and
By substitution.
Substitution is the progressive reduction of agricultural products to simple industrial inputs that allows replacement by increasingly non-agricultural components. Margarine, manufactured from cheaper intermediate ingredients as a substitute for butter, is an early example of substitution. Sugar, salt, fats, and oils are the most commonly added ingredients to increase the added value of foods (taking advantage of the biological fondness for sweetness and the easier to overcome satiety of sweet and fat foods).15 In 2002, more than 11 300 new food products were introduced in the United States alone.16
Global production of diet
Diets across the globe are being shaped by a concentrated and global food industry that is continually battling to increase demand and sales. Public health attempts to restrict this are being resisted fiercely. The food industry tactics are similar to those used by the tobaccoindustry—supplyingmisinformation, use of supposedly conflicting evidence, and hiding negative data.
Firstly, there is the half true contention that there is no such thing as an unhealthy food, only unhealthy diets. Presumably, an unhealthy diet is more likely to be made up largely of unhealthy foods than healthy foods. Healthy foods might be defined as those foods having characteristics that contribute to a diet that is in line with national dietary guidelines. Secondly, the industry contends that the problem is not the excessive diet but the reduction in physical activity. Again this half truth ignores two factors: that a healthy diet (with an energy content appropriate to the reduced energy needs but still providing adequate micronutrients and other food constituents) can mitigate the weight gaining effect of reduced activity and the evidence showing that dietary composition can predict body weight and waist and hip circumference.19
Summary points
Large multinational companies control much of what we eat
The convenience and availability of energy dense foods is contributing to the obesity epidemic
The food industry is resisting public health attempts to change current practices
Global strategies are needed similar to those used against the tobacco industry
Thirdly, the industry uses a smoke screen of apparently conflicting scientific data about sugars and different types of fats. Although scientific knowledge is still incomplete, it is less divided than the industry would have the public believe. This is shown by the recent World Health Organization's technical report on diet, nutrition and the prevention of chronic diseases; both food industry and civil society groups were able to comment on the draft document, and compromises were made in the final report.20
Fighting back
Bettcher D, Subramanian C, Guindon E. Confronting the tobacco epidemic in an era of trade liberalization. Geneva: Commission on Macroeconomics and Health, World Health Organization, 2001. (Paper No WG4:8.)
Collin J. Think global, smoke local: transnational tobacco companies and cognitive globalisation. In: Kelley L, ed. Health impacts of globalisation: towards global governance. New York: Palgrave, Macmillan, 2002: 61-86.
Joossens L, Raw M. Cigarette smuggling in Europe: who really benefits? Tobacco Control 1998;7: 66-71.
Hardeman W, Griffin S, Johnston M, Kinmonth AL, Wareham NJ. Interventions to prevent weight gain: a systematic review of psychological models and behaviour change methods. Int J Obes Relat Metab Disord 2000;24: 131-43.
Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors. JAMA 2003;289: 76-9.
Ebbeling CB, Pawiak DB, Ludwig DS. Childhood obesity: public-health crisis, common sense cure. Lancet 2002;360: 473-82.
Grummer-Strawn L, Hughes M, Khan LK, Martorell R. Obesity in women from developing countries. Eur J Clin Nutr 2000;54: 247-52.
American Institute for Cancer Research. Food, nutrition, and the prevention of cancer: a global perspective. Washington, DC: AICR, 1997.
Pinstrep-Andersen P, Babinard J. Globalisation and human nutrition: opportunities and risks for the poor in developing countries. Afr J Food Nutr Sci 2001;1: 9-18.
Drewnoski A, Popkin BM. The nutrition transition: new trends in the global diet. Nutr Rev 1997;55(2): 31-43.
Khan MK, Bowman B. Obesity: a major public health problem. Annu Rev Nutr 1999;19: xiii-xvii.
Gardner G, Halweil B. Underfed and overfed: the global epidemic of malnutrition worldwide. Washington, DC: Worldwide Watch, 2000.
Lang T. Trade, public health and food. In: McKee M, Garner P, Stott R, eds. International co-operation in health. Oxford: Oxford University Press, 2001: 81-108.
Jacobsen MF. Liquid candy: how soft drinks are harming Americans' health. Washington, DC: Center for Science in the Public Interest, 2000.
Egger G, Swinburn B. An "ecological" approach to the obesity epidemic. BMJ 1997;315: 477-80.
Nestle M. Food politics: how the food industry influences nutrition and health. San Francisco: University of California Press, 2003.
Boyd K, Watts M. "Just in time" chicken rearing. In: Goodman D, Watts M, eds. Globalising food: agrarian questions and global restructuring. London: Routledge, 1997: 180-210.
Reardon T, Berdegue JA. The rapid rise of supermarkets in Latin America: challenges and opportunities for development. Dev Policy Rev 2002;4: 371-88.
Bhargava A, Guthrie JF. Unhealthy eating habits, physical exercise and macronutrient intakes are predictors of anthropometric indicators in the women's health trial: feasibility study in minority populations. Br J Nutr 2002;88: 719-28.
World Health Organization. Diet, nutrition and the prevention of chronic diseases: a report of a joint WHO/FAO expert consultation. Geneva: WHO, 2003. (Technical Report Series 916.)
Aguayo VM, Ross JS, Kanon S, Ouedraogo AN. Monitoring compliance with the international code of marketing of breastmilk substitutes in west Africa: multisite cross sectional survey in Togo and Burkina Faso. BMJ 2003;326: 127.
Taylor AL. An international regulatory strategy for global tobacco control. Yale J Int Law 1996;21: 257-327.
Chopra M, Galbraith S, Darnton-Hill I. A global response to a global problem: the epidemic of overnutrition. Bull World Health Organ 2002;80: 952-8.(Mickey Chopra, senior lec)
Correspondence to: M Chopra mchopra@uwc.ac.za
Campaigns to promote healthy eating are undermined by the ubiquity of processed, energy dense foods. A global strategy is now needed to tackle the rising prevalence of obesity
Introduction
In the United States, obesity has risen by 74% in the past decade, with at least one in five adults now classified as obese.5 Similar trends are seen in most Western countries.6 In the Middle East and North Africa, and in much of Eastern Europe and Latin America, levels of overweight and obesity in women are similar to, or exceed, those of the United States.7
Total energy (calories) supplied by food and beverages has increased as food has become more processed and more energy dense. In North America, fat and sugar account for more than half the total dietary energy intake.8 These changing dietary patterns are becoming mirrored in developing countries. For all developing countries combined, the per capita supply of beef, mutton, goat, pork, poultry, eggs, and milk rose by an average of 50% between 1973 and 1996.9 The transition towards a more energy dense diet is also occurring at much lower income levels than previously.10
Obesogenic environment
An important feature of global food systems has been the consolidation of agricultural, food, and retail companies into large transnational corporations. More than half the market in most main foodstuffs in Europe and America is produced by a handful of corporations such as Unilever. The challenge for these corporations is how to continue to make profits when the market for food is so saturated in developed countries (the food supply already contains 15.9 MJ (3800 kcal) for every adult and child in the United States—that is, nearly twice what is needed on a daily basis). The corporations are approaching this in several ways:
By convincing people to consume more, and more highly energy dense, foods through relentless advertising and ubiquity of outlets
By increasing serving size and adding price inducements to order the larger sizes
By opening up markets in transitional and developing countries, and
By substitution.
Substitution is the progressive reduction of agricultural products to simple industrial inputs that allows replacement by increasingly non-agricultural components. Margarine, manufactured from cheaper intermediate ingredients as a substitute for butter, is an early example of substitution. Sugar, salt, fats, and oils are the most commonly added ingredients to increase the added value of foods (taking advantage of the biological fondness for sweetness and the easier to overcome satiety of sweet and fat foods).15 In 2002, more than 11 300 new food products were introduced in the United States alone.16
Global production of diet
Diets across the globe are being shaped by a concentrated and global food industry that is continually battling to increase demand and sales. Public health attempts to restrict this are being resisted fiercely. The food industry tactics are similar to those used by the tobaccoindustry—supplyingmisinformation, use of supposedly conflicting evidence, and hiding negative data.
Firstly, there is the half true contention that there is no such thing as an unhealthy food, only unhealthy diets. Presumably, an unhealthy diet is more likely to be made up largely of unhealthy foods than healthy foods. Healthy foods might be defined as those foods having characteristics that contribute to a diet that is in line with national dietary guidelines. Secondly, the industry contends that the problem is not the excessive diet but the reduction in physical activity. Again this half truth ignores two factors: that a healthy diet (with an energy content appropriate to the reduced energy needs but still providing adequate micronutrients and other food constituents) can mitigate the weight gaining effect of reduced activity and the evidence showing that dietary composition can predict body weight and waist and hip circumference.19
Summary points
Large multinational companies control much of what we eat
The convenience and availability of energy dense foods is contributing to the obesity epidemic
The food industry is resisting public health attempts to change current practices
Global strategies are needed similar to those used against the tobacco industry
Thirdly, the industry uses a smoke screen of apparently conflicting scientific data about sugars and different types of fats. Although scientific knowledge is still incomplete, it is less divided than the industry would have the public believe. This is shown by the recent World Health Organization's technical report on diet, nutrition and the prevention of chronic diseases; both food industry and civil society groups were able to comment on the draft document, and compromises were made in the final report.20
Fighting back
Bettcher D, Subramanian C, Guindon E. Confronting the tobacco epidemic in an era of trade liberalization. Geneva: Commission on Macroeconomics and Health, World Health Organization, 2001. (Paper No WG4:8.)
Collin J. Think global, smoke local: transnational tobacco companies and cognitive globalisation. In: Kelley L, ed. Health impacts of globalisation: towards global governance. New York: Palgrave, Macmillan, 2002: 61-86.
Joossens L, Raw M. Cigarette smuggling in Europe: who really benefits? Tobacco Control 1998;7: 66-71.
Hardeman W, Griffin S, Johnston M, Kinmonth AL, Wareham NJ. Interventions to prevent weight gain: a systematic review of psychological models and behaviour change methods. Int J Obes Relat Metab Disord 2000;24: 131-43.
Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors. JAMA 2003;289: 76-9.
Ebbeling CB, Pawiak DB, Ludwig DS. Childhood obesity: public-health crisis, common sense cure. Lancet 2002;360: 473-82.
Grummer-Strawn L, Hughes M, Khan LK, Martorell R. Obesity in women from developing countries. Eur J Clin Nutr 2000;54: 247-52.
American Institute for Cancer Research. Food, nutrition, and the prevention of cancer: a global perspective. Washington, DC: AICR, 1997.
Pinstrep-Andersen P, Babinard J. Globalisation and human nutrition: opportunities and risks for the poor in developing countries. Afr J Food Nutr Sci 2001;1: 9-18.
Drewnoski A, Popkin BM. The nutrition transition: new trends in the global diet. Nutr Rev 1997;55(2): 31-43.
Khan MK, Bowman B. Obesity: a major public health problem. Annu Rev Nutr 1999;19: xiii-xvii.
Gardner G, Halweil B. Underfed and overfed: the global epidemic of malnutrition worldwide. Washington, DC: Worldwide Watch, 2000.
Lang T. Trade, public health and food. In: McKee M, Garner P, Stott R, eds. International co-operation in health. Oxford: Oxford University Press, 2001: 81-108.
Jacobsen MF. Liquid candy: how soft drinks are harming Americans' health. Washington, DC: Center for Science in the Public Interest, 2000.
Egger G, Swinburn B. An "ecological" approach to the obesity epidemic. BMJ 1997;315: 477-80.
Nestle M. Food politics: how the food industry influences nutrition and health. San Francisco: University of California Press, 2003.
Boyd K, Watts M. "Just in time" chicken rearing. In: Goodman D, Watts M, eds. Globalising food: agrarian questions and global restructuring. London: Routledge, 1997: 180-210.
Reardon T, Berdegue JA. The rapid rise of supermarkets in Latin America: challenges and opportunities for development. Dev Policy Rev 2002;4: 371-88.
Bhargava A, Guthrie JF. Unhealthy eating habits, physical exercise and macronutrient intakes are predictors of anthropometric indicators in the women's health trial: feasibility study in minority populations. Br J Nutr 2002;88: 719-28.
World Health Organization. Diet, nutrition and the prevention of chronic diseases: a report of a joint WHO/FAO expert consultation. Geneva: WHO, 2003. (Technical Report Series 916.)
Aguayo VM, Ross JS, Kanon S, Ouedraogo AN. Monitoring compliance with the international code of marketing of breastmilk substitutes in west Africa: multisite cross sectional survey in Togo and Burkina Faso. BMJ 2003;326: 127.
Taylor AL. An international regulatory strategy for global tobacco control. Yale J Int Law 1996;21: 257-327.
Chopra M, Galbraith S, Darnton-Hill I. A global response to a global problem: the epidemic of overnutrition. Bull World Health Organ 2002;80: 952-8.(Mickey Chopra, senior lec)