Sustainable Agriculture Part 7

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THE EARTHSCAN READER IN SUSTAINABLE AGRICULTURE

EDITED BY JULES PRETTY

EARTHSCAN          2005

PART VII

 

PART IV: PERSPECTIVES FROM INDUSTRIALIZED COUNTRIES

Perspective 20: Diet and Health: Diseases and Food by Tim Lang and Michael Heasman

Let Reason rule in man, and he dares not trespass against his fellow-creature, but will do as he would be done unto. For Reason tells him, is thy neighbour hungry and naked today, do thou feed him and clothe him, it may be thy case tomorrow, and then he will be ready to help thee.

Gerrard Winstanley, English Leveller, 1609-1676

Core arguments

The Productionist paradigm is critically flawed in respect of human health. Half a century ago it responded to issues then seen as critical but which now require radical revision. While successfully raising the calorific value of the world food supply, it has failed to address the issue of quality, and as a result, there is now a worldwide legacy of externalized ill-health costs. The world’s human health profile is now very mixed. Within the same populations, in both developed and developing countries, there exists diet-related disease due both to under- and over-consumption. The pattern of diet that 30 years ago was associated with he affluent West is increasingly appearing in the developing countries, in a phenomenon known as the ‘nutrition transition’: while the incidence of certain diet-related diseases has decreased, such a heart disease in the West, others are increasing, particularly diabetes and obesity worldwide, and heart disease in the developing world. Massive global inequities in income and expectations contribute to this double burden of disease, and current policies are failing to address it.

Introduction

One of the key Food Wars is over the impact of the modern diet on human health. In the last quarter of the 20th century, nutrition moved from the sidelines of public health to being central to the marketing of foodstuffs, and major public health campaigns urged consumers to improve their diets.

This human health dimension is central to our critique of the Productionist paradigm in two respects. First, even though global food production has increased to meet caloric needs, its nutritional content may be less than desirable. Second, food distribution remains deficient: nearly a billion people remain malnourished. In this chapter, we explore the relationship between diet and the range of disease and illnesses that are associated with food choices. We discuss, too, the existence of gross inequalities within and between countries in the form of food poverty amidst food abundance and wealth.

In late 2002 and 2003, a wave of new public health reports reminded the world that diet is a major factor in the causes of death and morbidity. Although deeply unpalatable to some sections of the food industry, these reports were sober reminders of the enormity and scale of the public health crisis. The joint WHO and FAO’s 2003 report on diet, nutrition and the prevention of chronic diseases drew attention to high prevalence of diseases which could be prevented by better nutrition, including:

v  obesity;

v  diabetes;

v  cardiovascular diseases;

v  cancers;

v  osteoporosis and bone fractures;

v  dental disease.

Of course, these diseases are not solely exacerbated by poor diet but also by lack of physical activity. In truth this report was only reiterating the story of nutrition’s impact on public health that had been rehearsed for many years, and the evidence for which was judged to be remarkably sound, but as Dr Gro-Harlem Brundtland, then the Director-General of the WHO, stated in the report: ‘What is new is that we are laying down the foundation for a global policy response.” To this end, the WHO set up an international consultation dialogue to prepare its global strategy on diet, physical activity and health, scheduled to be launched in 2004. By international agency standards, this relatively speedy shift from evidence to policy making indicates the real urgency of the problem. The draft strategy was launched ahead of schedule in December 2003.

Already by 2002, the WHO had produced a major review of the national burdens that such disease cause. Of the top ten risk factors associated with non-communicable diseases, food and drink contribute to eight (with the two remaining – tobacco and unsafe sex – not associated with diet and food intake):

v  blood pressure;

v  cholesterol;

v  underweight;

v  fruit and vegetable intake;

v  high body mass index;

v  physical inactivity;

v  alcohol;

v  unsafe water, sanitation and hygiene.

The 2003 World Cancer Report, the most comprehensive global examination of the disease to date, the WHO stated that cancer rates could further increase by 50% to 15 million new cases in 2020. To stem the rise of this toll, the WHO and the International Agency for Research on Cancer (the IARC) argued that 3 issues in particular need to be tackled:

v  tobacco consumption (still the most important immediate avoidable risk to health).

v  Healthy lifestyle and diet, in particular the frequent consumption of fruit and vegetables and the taking of physical activity; early detection and screening of diseases to allow prevention and cure.

v  In addition to these UN reports, the International Association for the Study of Obesity (the IASO) revised its figures of the global obesity pandemic: it estimates that 1.7 billion people are overweight or obese, a 50% increase on previous estimates. The IASO’s International Obesity Task Force stated that the revised figures meant that most governments were simply ignoring one of the biggest risks to world population health.

These reports testify to an extensive body of research and evidence from diverse sources around the world of the link between food availability, consumption styles and specific patterns of disease and illness. Table 20.1 confirms some of the diet-related causes of death throughout the world. Good health and longevity were intended to result from ensured sufficiency of supply; at the beginning of the 21st century, far from diet-related ill health being banished from the policy agenda, it appears to be experiencing a renewed crisis.

  • Under the old Productionist paradigm, the main focus was under-nutrition. At the end of the 20th century, with disease and obesity rampant, a new focus must be placed on diet and inappropriate eating.
  • The developed world must now confront one of the most challenging food and health disasters ever to face humankind: an epidemic of obesity and the prospect of a new wave of diet-related disease.
  • A 1995 FAO review stated: ‘Hunger persists in developing countries at a time when global food production has evolved to a stage when sufficient food is produced to meet the needs of every person on the planet.’
  • Over-consumption and under-consumption coexist. There is gross inequality of global distribution and availability of food energy. Diseases associated with deficient diet account for 60% of years of life lost in the established market economies.

 

The nutrition transition

In a series of papers, Professor Barry Popkin and his colleagues have argued that there is what they term a ‘nutrition transition’ occurring in the developing world, associated primarily with rising wealth. The thesis, which has been extensively supported by country and regional studies, argues simply that diet-related ill health previously associated with the affluent West is now becoming increasingly manifest in developing countries. The ‘nutrition transition’ suggests shifts in diet from one pattern to another: for example, from a restricted diet to one that is high in saturated fat, sugar and refined foods, and low in fibre. This transition is associated with two other historic processes of change: the demographic and epidemiological transitions. Demographically, world populations have shifted from patterns of high fertility and high mortality to patterns of low fertility and low mortality. In the epidemiological transition, there is a shift from a pattern of disease characterized by infections, malnutrition and episodic famine to a pattern of disease with a high rate of the chronic and degenerative diseases. This change of disease pattern is associated with a shift from rural to urban and industrial lifestyle.

  • Consumers might enjoy the new variety of foods that greater wealth offers but they are often unaware of the risk of disease than can follow.

Nutrition may have recently become a key notion in modern dietary thinking but it only echoes the insights of an earlier generation of researchers which included nutrition and public health pioneers such as Professors Trowell and Burkitt, whose observations from the 1950s to the 1980s led them to question ‘whether Western influence in Africa, Asia, Central and South America and the Far East is unnecessarily imposing our diseases on other populations who are presently relatively free of them.’

  • In Saudi Arabia meat consumption doubled and fat consumption tripled between the mid-1970s and the early 1990s.

In China, the national health profile began to follow a more Western pattern of diet-related disease as the population gradually urbanized, coinciding with an increase in degenerative diseases. Consumption of legumes such as soyabean was replaced by animal protein in the form of meat. One expert nutritional review of this problem concluded that exhorting the Chinese people to consume more soy when they were voting with their purses to eat more meat would be ineffective ‘in the context of an increasingly free and global market’. Such studies can suggest that the battle to prevent Western diseases in the developing world appears already to have been lost. If the nutrition transition is weakening health in China, the world’s most populous and fastest economically growing nation, which has 22% of the world’s population but only 7% of its land, what chance is there for diet-related health improvements throughout the developing world?

  • As populations become richer, they substitute cereal foods for higher-value protein foods such as milk, dairy products and meat, increased consumption of which is associated with Westernization of ill health.

 

Three categories of malnutrition: underfed, overfed, and badly fed

More than 2 billion people in the world today have their lives blighted by nutritional inadequacy. On one hand, half of this number do not have enough to eat; on the other hand, a growing army of people exhibit the symptoms of overfeeding and obesity. In both cases, the international communities are floundering for solutions, and malnutrition results, as indicated by the following table.

One of the particularly tragic consequences of undernourishment is its impact on the world’s children. UNICEF calculates that 800 million children suffer malnutrition at any given time. High proportions of Asian and African mothers are undernourished, largely due to seasonal food shortages, especially in Africa. About 243 million adults in developing countries are deemed to be severely undernourished. This type of adult under-nutrition can impair work capacity and lower resistance to infection.

Against a rapid growth in world population, well-informed observers agree that greater food production is needed for the future. One estimate suggests that by 2020 there will be 1 billion young people growing up with impaired mental development due to poor nutrition. At a conservative estimate, this means there will be 40 million young people added to the total each year.

The obesity epidemic

As early as 1948, there were medical international groups researching the incidence of obesity in various countries.

  • Today, overweight and obesity are key risk factors for chronic and non-communicable diseases.
  • In developing countries obesity is more common amongst people of higher socio-economic status and in those living in urban communities.
  • In more affluent countries, it is associated with lower socio-economic status, especially amongst women and rural communities.

By 2000, the WHO was expressing alarm that more than 300 million people were defined as obese, with 750 million overweight, ie pre-obese: over a billion people deemed overweight or obese globally. But by 2003, this figure had been radically revised upwards when the International Association for the Study of Obesity (the IASO) calculated that up to 1.7 billion people were now overweight or obese.

  • In 2003, 6.3% of US women, that is 1 in 16, were morbidly obese, with a body mass index of 40 or more.
  • Figure 20.9 shows how, in a remarkably short time, the rate of obesity within countries is rising.
  • Rising obesity rates among children are particularly troubling to health professionals, as this trend suggests massive problems of degenerative disease for the future.
  • In Jamaica and Chile 1 in 10 children is obese.
  • A child’s weight can be thrown off balance by a daily consumption of only one sugar-sweetened soft drink of 120kcals; over 10 years, this intake would turn into 50kg of excess growth.
  • Health education seems to be powerless before this rising tide of obesity.
  • As far back as 1986, the economic costs of illness associated with overweight in the US were estimated to be $39 billion; today the estimated cost of obesity and overweight is about $117 billion.
  • The rise in US obesity is dramatic: between 1991 and 2001, adult obesity increased by 74%.

 

The connection between overweight and health risk is alarmingly highlighted by the following list of the physical ailments that an overweight population (with a BMI higher than 25) is at risk of:

v  High blood pressure, hypertension;

v  High blood cholesterol, dyslipidemia;

v  Type-II (non-insulin-dependent) diabetes;

v  Insulin resistance, glucose intolerance;

v  Hyperinsulinaemia;

v  Coronary heart disease;

v  Angina pectoris;

v  Congestive heart failure;

v  Stroke; gallstones;

v  Cholescystitis and cholelithiasis;

v  Gout;

v  Osteoarthritis;

v  Obstructive sleep apnea and respiratory problems;

v  Some types of cancer (such as endometrial, breast, prostate and colon);

v  Complications of pregnancy; poor female reproductive health (such as menstrual irregularities, infertility and irregular ovulation);

v  Bladder control problems (such as stress incontinence);

v  Uric acid nephrolithiasis;

v  Psychological disorders (such as depression, eating disorders, distorted body image, and low self esteem).

  • The ill-health that results is paid for either in direct costs or in societal drag – lost opportunities, inequalities and lost efficiencies. This is why policy makers have to get to grips with obesity and the world’s weight problem.

 

Both obesity and overweight are preventable. At present the debate about obesity is divided about which of three broad strategies of action is the best to address. One strand argues that it is a problem caused by over-consumption (diet and the types of food) and over-supply; another that it is lack of physical activity; and the third that there might be a matter of genetic predisposition. Certainly the emphasis has to be on changing the environmental determinants that allow obesity to happen. A pioneering analysis by Australian researchers in the mid-1990s proposed that the obesity pandemic could only be explained in ‘ecological’ terms: Professor Garry Egger and Boyd Swinburn set out environmental determinants such as transport, pricing and supply; they claimed that environmental factors were so powerful in upsetting energy balances that obesity could be viewed as ‘a normal response to an abnormal environment’. So finely balanced are caloric intake and physical activity that even slight alterations in their levels can lead to weight gain. Swinburn and Egger assert that no amount of individual exhortation will reduce worldwide obesity; transport, neighborhood layout, home environments, fiscal policies and other alterations of supply chains must be tackled instead.

Calculating the burden of diet-related disease

During the 1990s, world attention was given to calculating the costs of what has been called ‘the burden of disease’. Five of the ten leading causes of death in the world’s most economically advanced country, the US, were, by the 1980s, diet-related: coronary heart disease, some types of cancer, stroke, diabetes mellitus and atherosclerosis. Another three – cirrhosis of the liver, accidents and suicides – were associated with excessive alcohol intake. Together these diseases were accounting for nearly 1.5 million of the 2.1 million deaths in the US. Only two categories in the top ten – chronic obstructive lung disease and pneumonia and influenza – had no food connection.

  • In a 1990s study published by the World Bank, The Global Burden of Disease, heart disease accounted for 6.26 million deaths; stroke 4.38 million; acute respiratory infections 4.3 million; and cancers 6 million.

 

The financial costs

  • Health care costs are rising rapidly in many developed and developing economies. Growth of health expenditures is sometimes higher than the growth pf GDP. Health ministries are locked in a model which tends to be curative rather than preventative.
  • The UK health care system costs £68 billion for around 60 million people and is anticipated to rise to £184 billion by 2022-2023.

 

Coronary heart disease (CHD)

Food-related cancers

Diabetes

Food safety and foodborne diseases

  • Food safety problems include risks from: veterinary drug and pesticide residues; food additives; pathogens; environmental toxins; persistent organic pollutants such as dioxins; and unconventional agents such as prions associated with BSE.

 

Food poverty in the Western world

  • The new era of globalization has unleashed a reconfiguration of social divisions both between and within countries. Food poverty in the UK is far higher than any other EU country, where inequalities of income and health widened under the Conservative government of 1979-1997.
  • This was the converse of the post-World War II years of Keynesian social democratic policies during which inequalities narrowed.
  • During the 1990s, 11 million Americans lived in households which were ‘food insecure’ with a further 23 million living in households which were ‘food insecure without hunger’. At least 4 million children under 12 were hungry and an additional 9.6 million were at risk of hunger during at least one month of the year.
  • The US spent over $25 billion on federal and state programmes to provide extra food for its 25 million citizens in need of nutritional support.

 

Implications for policy

  • For policy makers, the uncomfortable fact is that the pattern of diet-related diseases appears to be closely associated with the Productionist paradigm.
  • Whilst the paradigm had as its objective the need to produce enough food to feed people, its harvest of ill health was mainly sown in the name of economic development.
  • The public health message is clear: if diet is inappropriate or inadequate, population ill health will follow.
  • Diet is one of the most alterable factors in human health, but despite strong evidence for intervention, public policy has only implemented lesser measures such as labelling and health education while the supply chain remains legitimised to produce the ingredients of heart disease, cancer, obesity and their diet-related degenerative diseases.
  • Policy attention needs to shift from the overwhelming focus, enshrined in the Productionist paradigm, on under-consumption and under-supply to a new focus on the relationship between the over-supply of certain foodstuffs, excessive marketing and malconsumption, and to do so simultaneously within and between countries.
  • The food supply chain must be re-framed and must target wider, more health-appropriate goals.
  • While the 1948 Universal Declaration of Human Rights asserted the right to food health for all, even into the new millennium the call is still not being adequately met, and, for humanity’s sake, it must now be pursued with more vigour.

 

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