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Specific policies to tackle diet-related NCD in Europe

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Presented by Prof. Carlos A. Monteiro of the Center for Epidemiological Studies on Health and Nutrition, School of Public Health, University of São Paulo, Brazil, at the WHO European Ministerial ...

Presented by Prof. Carlos A. Monteiro of the Center for Epidemiological Studies on Health and Nutrition, School of Public Health, University of São Paulo, Brazil, at the WHO European Ministerial Conference on Nutrition and Noncommunicable Diseases in the Context of Health 2020, on 4 July 2013 in Vienna, Austria.

Disclaimer: WHO is not responsible for the content of presentations made by external speakers at its meetings and conferences. This presentation is published here with the speaker's consent, only for information purpose.

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    Specific policies to tackle diet-related NCD in Europe Specific policies to tackle diet-related NCD in Europe Presentation Transcript

    • Carlos A. Monteiro carlosam@usp.br Center for Epidemiological Studies on Health and Nutrition School of Public Health, University of São Paulo European Ministerial Conference on Nutrition and Noncommunicable Diseases in the context of Health 2020. Vienna, 4-5 July 2013 Specific policies to tackle diet-related NCD in Europe
    • Action Plan for implementation of the European Strategy for the Prevention and Control of Noncommunicable Diseases 2012−2016 Specific policies to tackle diet-related NCD • Policies to reduce the consumption of processed foods – Actions • Build the case for fiscal mechanisms to support healthy dietary choices • Limit children’s and young people’s exposure to the marketing of foods high in salt, fat and sugar, and sugar-sweetened beverages • Policies aiming the reformulation of processed foods – Actions • Work alongside industry to develop a timetable for removing trans fats from foods intended for the European market • Develop and implement salt reduction strategies with core elements in line with WHO
    • Processed foods: reduction or reformulation?
    • • Diet and the burden of disease in Europe • Dietary trends in Europe with a focus on the extent and purpose of food processing • What is wrong with ultra-processed food and drink products and what can be fixed with product reformulation? • Policy implications
    • • Diet and the burden of disease in Europe • Dietary trends in Europe with a focus on the extent and purpose of food processing • What is wrong with ultra-processed food and drink products and what can be fixed with product reformulation? • Policy implications
    • 2013 20 most important risk factors WESTERN EUROPE
    • 3. OVERWEIGHT/OBESITY 2013WESTERN EUROPE
    • 3. OVERWEIGHT/OBESITY 7. DIET LOW IN FRUITS 9. DIET LOW IN NUTS/SEEDS 13. DIET LOW IN VEGETABLES 15. DIET LOW IN SEA FOODS 18. DIET LOW IN FIBRE (PLANT FOODS) 2013 16. DIET LOW IN WHOLE GRAINS WESTERN EUROPE
    • 3. OVERWEIGHT/OBESITY 7. DIET LOW IN FRUITS 9. DIET LOW IN NUTS/SEEDS 13. DIET LOW IN VEGETABLES 15. DIET LOW IN SEA FOODS 18. DIET LOW IN FIBRE (PLANT FOODS) 12. DIET HIGH IN PROCESSED MEAT 2013 16. DIET LOW IN WHOLE GRAINS WESTERN EUROPE
    • 3. OVERWEIGHT/OBESITY 7. DIET LOW IN FRUITS 9. DIET LOW IN NUTS/SEEDS 13. DIET LOW IN VEGETABLES 15. DIET LOW IN SEA FOODS 18. DIET LOW IN FIBRE (PLANT FOODS) 12. DIET HIGH IN PROCESSED MEAT 10. DIET HIGH IN SODIUM 2013 16. DIET LOW IN WHOLE GRAINS WESTERN EUROPE
    • 3. OVERWEIGHT/OBESITY 5. DIET LOW IN FRUITS 8. DIET LOW IN NUTS/SEEDS 13. DIET LOW IN VEGETABLES 16. DIET LOW IN SEA FOODS 11. DIET LOW IN WHOLE GRAINS 19. DIET LOW IN FIBRE (PLANT FOODS) 9. DIET HIGH IN SODIUM 15. DIET HIGH IN PROCESSED MEAT CENTRAL EUROPE 2013
    • 4. OVERWEIGHT/OBESITY 5. DIET LOW IN FRUITS 8. DIET LOW IN NUTS/SEEDS 12. DIET LOW IN VEGETABLES 13. DIET LOW IN SEA FOODS 11. DIET LOW IN WHOLE GRAINS 16. DIET LOW IN FIBRE (PLANT FOODS) 9. DIET HIGH IN SODIUM 15. DIET HIGH IN PROCESSED MEAT EASTERN EUROPE 2013 19. DIET HIGH IN TRANS FATS
    • Extra calories in the European diet are not coming from foods, at least not from fresh or minimally processed foods. Hardly only from processed meat. Excess of sodium and trans fats suggests other processed foods are contributing to extra calories
    • • Diet and the burden of disease in Europe • Dietary trends in Europe with a focus on the extent and purpose of food processing • What is wrong with ultra-processed food and drink products and what can be fixed with product reformulation? • Policy implications
    • Dietary trends in Europe - Food supply data (FAO) - Retail sales (Euromonitor)
    • 3000 3100 3200 3300 3400 3500 3600 1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 Per capita total food supply WESTERN EUROPE: 1961-2009 Kcal/day Source: FAOSTAT
    • 3000 3100 3200 3300 3400 3500 1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 Per capita total food supply EUROPE: 1961-2009 Kcal/day Source: FAOSTAT
    • Foods whose caloric share in total food supply changed by >= 1 percentage point WESTERN EUROPE: 1961 to 2009 POTATOES RYE WHEAT OILS AND FATS MAIZE POULTRY MEAT SUGAR AND SWEETENERS -8 -6 -4 -2 0 2 4 6 8 Source: Food Balance Sheets from FAOSTAT Percentage points
    • Foods whose caloric share in total food suppy changed by >= 1 percentage point EUROPE: 1961 to 2009 WHEAT RYE POTATOES OILS AND FATS PIG AND POULTRY MEAT -12 -10 -8 -6 -4 -2 0 2 4 6 8 Source: Food Balance Sheets from FAOSTAT Percentage points
    • Dietary trends in Europe - Food supply data (FAO) - Retail sales (Euromonitor)
    • Euromonitor provides information on grocery stores and supermarkets retail sales of: 1) Minimally processed foods such as vegetables, fruits, nuts, pulses, roots, and meat, fish, and eggs 2) Oils and fats, and table sugar, which are food products used as culinary ingredients (processed culinary ingredients) 3) Savory and sweet snacks, frozen and chilled ready meals, and soft drinks, which are ready to consume products (ultra-processed ready-to-consume food products)
    • 240 245 250 255 260 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Source: Euromonitor International 249.1 kg/year 253.3 kg/year Minimally processed foods Annual per capita retail sales of foods and food products in West Europe (1999-2012)
    • 8 10 12 14 16 18 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Source: Euromonitor International 15.4 litres 16.8 litres 10.4 kilos 10.1 kilos Annual per capita retail sales of foods and food products in West Europe (1998-2012) Processed culinary ingredients
    • 21 22 23 24 25 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Source: Euromonitor International 24,8 kilos 21,7 kilos Annual per capita retail sales of foods and food products in West Europe (1998-2012) Ultra-processed ready-to-consume products
    • 30 35 40 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Source: Euromonitor International 39.7 kilos 31.3 kilos Annual per capita retail sales of foods and food products in West Europe (1998-2012) Ultra-processed ready-to-consume products
    • 100 120 140 160 180 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Source: Euromonitor International 177 litres (485 ml/day) 129 litres (356 ml/day) Annual per capita retail sales of foods and food products in West Europe (1998-2012) Ultra-processed ready-to-consume products
    • 100 120 140 160 180 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Source: Euromonitor International Ultra-processed ready-to-consume products Increases in annual per capita sales from 1998 to 2012 Western Europe Products Increase in 14y Kcal Snacks + 3.1 kg ~ 9,000 kcal Ready meals + 8.5 kg ~ 21,000 kcal Soft drinks + 48 litres ~ 20,000 kcal Total ~ 50,000 kcal (or 3-4 kilos)
    • 0 10 20 30 40 50 60 1939 1953 1969 1984 2001 Changes in household purchases of foods and food products CANADA: 1939-2001 % of total calories Source: Moubarac J-C et al 2013. 54,9% 24.4%
    • 0 10 20 30 40 50 1987 1996 2003 2009 Changes in household purchases of foods and food products BRAZIL: 1987-2009 % of total calories Source: Martins et al 2013. 29.6% 18.7%
    • Why ultra-processed products are displacing foods and culinary ingredients everywhere?
    • • The ingredients and formulation of ultra-processed products make them: – accessible (relatively cheap) – highly convenient (long duration, ready-to- consume) – very attractive (intense sensorial properties) • Ultra-processed products are extremely profitable (low cost ingredients, long shelf life, branded products) and this allows heavy investments in marketing • But not a win-win game …
    • • Diet and the burden of disease in Europe • Dietary trends in Europe with a focus on the extent and purpose of food processing • What is wrong with ultra-processed food and drink products and what can be fixed with product reformulation? • Policy implications
    • www.thelancet.com February 12, 2013 http://dx.doi.org/10.1016/S0140-6736(12)62089-3
    • ‘Ultra-processed products are assemblage of industrial ingredients obtained from the extraction, refinement, and transformation of constituents of raw foods with usually little or no whole food.’
    • Extracting substances from raw foods Oils, fats, flours, starches sugar, plant proteins, milk whey, remnants of meat ... Raw foods Hydrogenated oils, starch-modified sugars, hydrolyzed proteins, ex- truded meat extracts … Preservatives, stabilisers, emulsifiers, solvents, binders, bulkers, sweeteners, sensory enhancers, flavours, colours, other additives, synthetic micronutrients .. ULTRA- PROCESSED PRODUCT Transforming food substances into new ingredients No or minimal culinary actions Assembling, ‘cooking’, packaging … Ready-to- consume snacks, drinks, and ready meals Transforming food substances into additives
    • Oils, fats, flours, starches sugar, plant proteins, milk whey, remnants of meat ... Raw foods Hydrogenated oils, starch-modified sugars, hydrolyzed proteins, ex- truded meat extracts … Preservatives, stabilisers, emulsifiers, solvents, binders, bulkers, sweeteners, sensory enhancers, flavours, colours, other additives, synthetic micronutrients .. ULTRA- PROCESSED PRODUCT No or minimal culinary actions Snacks
    • Oils, fats, flours, starches sugar, plant proteins, milk whey, remnants of meat ... Raw foods Hydrogenated oils, starch-modified sugars, hydrolyzed proteins, ex- truded meat extracts … Preservatives, stabilisers, emulsifiers, solvents, binders, bulkers, sweeteners, sensory enhancers, flavours, colours, other additives, synthetic micronutrients .. ULTRA- PROCESSED PRODUCT No or minimal culinary actions Soft drinks
    • Oils, fats, flours, starches sugar, plant proteins, milk whey, remnants of meat ... Raw foods Hydrogenated oils, starch-modified sugars, hydrolyzed proteins, ex- truded meat extracts … Preservatives, stabilisers, emulsifiers, solvents, binders, bulkers, sweeteners, sensory enhancers, flavours, colours, other additives, synthetic micronutrients .. ULTRA- PROCESSED PRODUCT No or minimal culinary actions Ready meals
    • Extracting substances from raw foods Oils, fats, flours, starches sugar, plant proteins, milk whey, remnants of meat ... Raw foods Hydrogenated oils, starch-modified sugars, hydrolyzed proteins, ex- truded meat extracts … Preservatives, stabilisers, emulsifiers, solvents, binders, bulkers, sweeteners, sensory enhancers, flavours, colours, other additives, synthetic micronutrients .. ULTRA- PROCESSED PRODUCT Modifying substances extracted from raw foods No or minimal culinary actions Assembling, ‘cooking’, packaging … Formulations of food substances Transforming food substances into additives
    • Due to their ingredients and formulation, ultra- processed products as a group tend to have:  less protein  less dietary fiber  more free sugar  more total, saturated and trans fats  more sodium, less potassium … than average foods and dishes made up from foods and culinary ingredients Sources: Monteiro et al PHN 2011 and Moubarac PHN 2013
    • Due to their ingredients and formulation, ultra- processed products as a group tend to have:  less protein  less dietary fiber  more free sugar  more total, saturated and trans fats  more sodium, less potassium … than average foods and dishes made up from foods and culinary ingredients Sources: Monteiro et al PHN 2011 and Moubarac PHN 2013
    •  High energy density (all solid products) Prentice & Jebb (2003) Obes Rev. 4:187-94  Liquid calories (all sugared drinks) Vartanian et al (2007) Am J Public Health 97: 667-75  Hyper-palatability (all products) Kessler (2009) The End of Overeating. New York, Rodale.  Habituation/addiction (some products) Brownell and Gold (2012) Food and addiction. New York, Oxford University Press; Garber and Lustig (2012). Current Drug Abuse Reviews 4(3): 146-162. Moss M (2013) Salt Sugar Fat: How the Food Giants Hooked Us. New York, Random House  Mindless eating (all products) Cohen & Farley (2008) Prev Chronic Dis 2008;5:1-7  Aggressive marketing (most products) Several `intrinsic` features of ultra-processed products are liable to disrupt energy balance regulation and to induce overeating and therefore obesity
    • Country Foods + culinary ingredients Ready-to-consume products CANADA 2001 1.3 2.8 BELGIUM 1999 1.6 3.0 AUSTRIA 1999 1.7 3.1 FINLAND 1998 1.4 2.7 SPAIN 1999 1.9 2.7 GERMANY 1998 1.6 2,9 FRANCE 1991 1.5 2.6 UK 2008 1.4 2.8 BRAZIL 2008 1.9 2.9 COLOMBIA 2007 1.8 2.7 ALL - RANGE 1.3-1.9 2.6-3.1 ENERGY DENSITY (KCAL/G)
    • Garber AK, Lustig RH (2011) Is fast food addictive? Curr Drug Abuse Rev 2011 Sep;4(3):146-62. Habituation/ addiction
    • The marketing of ultra-processed products promotes compulsive overeating It is one after the other! The name says it all. Non-stop is simply irresistible. New brand of ultra-processed products in Brazil
    • 12.7 13.2 25.5 26.3 31.5 33 33.4 34.6 34.9 37.5 39.9 42.8 44.4 45.8 45.9 47 51.5 51.6 52.9 54.9 57.4 64 0 10 20 30 40 50 60 70 Ultra-processedproducts(%oftotalenergy) Estimates for the dietary share of ultra-processed products* * Estimated from national household food expenditure surveys for Brazil (HBS), Canada (FOODEX), Chile (EPF), Colombia (ENIG), Peru (ENAPREF) Mexico (ENIGH), Uruguay (EGIH), and the Data Food Networking (DAFNE) for all European countries, except UK (LCF), and from 24 h recall survey for USA ((HANES)
    • y = 10,894e0,017x R² = 0,7157 10 15 20 25 30 35 0 10 20 30 40 50 60 70 80 Colombia Mexico Chile Obesityinadults(%) Peru Ultra-processed products (% of total energy) Uruguay Brazil Dietary share of ultra-processed products and obesity in middle income countries (2006-2010) Source: Multi-country study on ultra-processed products and obesity (preliminary data) Latvia Croatia
    • y = 2,9528e0,0374x R² = 0,8332 0 5 10 15 20 25 30 35 0 10 20 30 40 50 60 70 80 UK Canada Obesityinadults(%) Dietary share of ultra-processed products and obesity in high income countries (1991-2010) Ultra-processed products (% of total energy) Belgium Italy US France Germany Spain Ireland Austria Finland Malta Norway Source: Multi-country study on ultra-processed products and obesity (preliminary data) Cyprus
    • • Diet and the burden of disease in Europe • Dietary trends in Europe with a focus on the extent and purpose of food processing • What is wrong with ultra-processed food and drink products and what can be fixed with product reformulation? • Policy implications
    • Business as usual (industry-driven product reformulation, marketing self - regulation etc)
    • Taxation and labeling and marketing controls on ultra-processed products, government-driven product reformulation, and policies to promote, support, and protect traditional food systems and healthy dietary patterns
    • Public actions to incentive, support, and protect traditional food systems and diets: learning from breast-feeding! ACTION HUMAN MILK MINIMALLY PROCESSED FOODS Promotion Information/education Information/education (health, environment, and culture arguments) Support Maternal leave, baby- friendly hospitals, human milk banks Subsidies and taxes, family agriculture support, government food procurement Protection Code to regulate the marketing of infant formulas Code to regulate the marketing of ultra- processed products
    • 0 3 6 9 12 15 1970 1980 1990 2000 2010 Source: Venancio and Monteiro 1998; PNDS 2007 Breast-feeding increased from 3 to14 months with incentive, support, and protection …
    • Dr Margaret Chan, Director-General of the World Health Organization Opening address at the 8th Global Conference on Health Promotion, Finland, Helsinki, 10 June 2013 `Efforts to prevent non-communicable diseases go against the business interests of powerful economic operators. In my view, this is one of the biggest challenges facing health promotion. As the new publication makes clear, it is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda, and Big Alcohol. All of these industries fear regulation, and protect themselves by using the same tactics. Research has documented these tactics well. They include front groups, lobbies, promises of self-regulation, lawsuits, and industry-funded research that confuses the evidence and keeps the public in doubt. Tactics also include gifts, grants, and …This is formidable opposition. Market power readily translates into political power. Let me remind you. Not one single country has managed to turn around its obesity epidemic in all age groups. This is not a failure of individual will-power. This is a failure of political will to take on big business.`