全球粮食安全与营养论坛 (FSN论坛)

A lot is said about the role of nutrition activists in advocating in this field. Strictly speaking, our role goes well beyond advocating; we are supposed to stand by those affected as claim holders for them to understand, organize, mobilize and act upon their nutrition and resulting NCDs problem so as to proactively demand changes be made by the respective duty bearers at each level.

This is not a semantic difference only. It must be seen as pertaining to the right to food and adequate nutrition. The existence of the human rights covenants duly ratified by most nations gives claim holders the power to demand and no longer beg for the State and industry to make changes. (Note that this also encompasses extraterritorial obligations or ETOs where the duty bearers are entities other than the State --could be donors or corporations among other).

This distinction is indeed important. Why? Because the organization and mobilization of claim holders ought to become a central activity of our work in public health nutrition.

The distinction between advocating and demanding also has a connotation for understanding that human rights go beyond individual rights to also cover collective rights.

Does this really apply to our work in public nutrition? Of course it does!

How? Take the problems of overweight, obesity and NCDs. Industry (and the influence they exert /buy) wants us to believe that it is individual behavior that is the target we should address. But we know better, don’t we? Clearly vested interests are behind this myth being sold to us. Big Food/Big Soda profit from influencing our eating behavior from childhood-on particularly selling us ultra-processed foods galore. But they now want to show social responsibility. So they propose reformulating their products with less sugar, less salt and no trans-fats… But still want us to continue to be hooked to consuming these fast foods! On the other hand, have you given it a thought that Big Pharma profits from selling us medicines to prevent/treat NCDs (or miracle pills to treat obesity)? So, why should they be active advocates of the right to good nutrition?

Beware that the NCDs recent New York summit and the recent WHO report on obesity are rather weak in making the point of the responsibility of industry. Does this surprise you? We know about the links and the lobbying of both transnational corporations and the rich states that house them (also now affecting UN agencies!).

[As a byline, on the undernutrition side, we have witnessed 50 years plus of foreign aid not addressing the basic causes of preventable malnutrition so clearly spelled out in the late Urban Jonsson’s conceptual framework of the causes of malnutrition].

This quick review of the current situation is brief to the point of a caricature, but is sufficient to ask two questions:

1. Is it ‘advocacy’ that we need when facing the-powers-that-bend-policy decisions? Would this be a bit like ‘putting the other cheek’? and

2. What do I/you then mean by claim holders ‘demanding’ the human right to food and nutrition as pertains to overweight, obesity and NCDs?

Use this space to comment.

Let us use our common sense and review what has changed?

Living material, that needs to grow and develop in their own time whilst being fed through a rich, nutritious and healthy soil, producing nutritious healthy plants, in their turn feeding healthy animals, is being manipulated to grow faster and cheaper by ‘modern’ agricultural mass production and processed by the food industry:

1. The mass meat production industry uses (chemical) hormones,  preventive chemical medication and the animals are fed a very poor diet with concentrates and GMO’s.
2. Meat has become cheaper, resulting in a higher meat consumption. The DRI (Dietary Reference Intake) is 0.8 grams of protein per kilogram of body weight. That is not even 70 grams per day for a human being of 85 kg.
3. The mass vegetable production industry uses endocrine disrupting pesticides, fertilizers and preventive chemical medicines on the worn out soil, resulting in less nutritious and ‘weak’ vegetables.
4. The food industry manipulates taste buds with engineered 'salt sugar fat-ratio's, making people addicted to their produce. Who can eat just one cookie?
5. Grains, especially wheat, are  being cultivated to increase the gluten content
6. Bread is not just baked with grains, extra gluten are being added to make it tastier
7. Gluten are being used in almost every processed food. More and more people are having allergic reactions to gluten.
8. Cows are manipulated into producing more A1 casein instead of the natural A2 casein. This is already also occurring in goats milk. A1 casein can create a bioactive opioid peptide and morphine-related compound called beta casomorphin-7 (BCM7).
9. All these processed and addictive products are being prepacked in Endocrine Disrupting Plastic packaging and coated cans and boxes (Bisphenol A). BPA leaks into oils and oily substances very easily. It also leaks into drinking water, when a plastic water bottle warms up. Most PET bottles are filled of while they are still warm.

The continuous intake of low amounts of antibiotics, which kill vital gut bacteria, the intake of too much addictive fast carbohydrates and sugars, which feed the harmful yeast and moulds in the gut, result in a poor metabolism and a putrid intestinal flora.
 
Yeasts and moulds, as well as allergic reactions to processed proteins (such as gluten and A1 casein), produce opioid-like substances, which leak through the mucosa, into the blood and flood into the brain. The opioid substances are also addictive.
 
Today’s western consumer is being overeating all this fast grown, less nutritious, addictive and gut bacteria destroying processed comfort/fast food, which is not being produced or marketed to feed the world, but to make humongous profits which only benefits the almighty ‘one percent’. Follow the money!

This addictive circle with hormonal dis-balances, emotional dis-balances, a foggy brain, a lazy couch and television -loving body (on which the processed foods are constantly promoted), is in my opinion the main cause for overweight and obesity (whilst obese people also becoming more and more underfed!), and it even leads to a more dumb, bored and very dissatisfied society.

The solution was already published in 2013: http://unctad.org/en/pages/PublicationWebflyer.aspx?publicationid=666 : Wake up before it is too late: Make agriculture truly sustainable now for food security in a changing climate.
 
Google around, I did..
https://www.sciencedaily.com/releases/2016/05/160519130105.htm : Antibiotics that kill gut bacteria also stop growth of new brain cells
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2235907/ : Evidence for sugar addiction: Behavioral and neurochemical effects of intermittent, excessive sugar intake
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714381/  : Sugar and Fat Bingeing Have Notable Differences in Addictive-like Behavior
http://www.npr.org/sections/thesalt/2013/02/26/172969363/how-the-food-industry-manipulates-taste-buds-with-salt-sugar-fat : How The Food Industry Manipulates Taste Buds With 'Salt Sugar Fat'
http://www.bbcgoodfood.com/howto/guide/how-much-meat-safe-eat : How much meat is safe to eat?
http://www.unep.org/pdf/WHO_HSE_PHE_IHE_2013.1_eng.pdf : World Health Organization: State of the Science of Endocrine Disrupting Chemicals 2012

Hello!

Here are some of my thoughts on the subject for what they are worth. Even though my main argument may not win many supporters, I hope it would be of some help.

Many thanks.

Lal.

Elements Crucial to Effectively Support Policies, Strategies and/or Programs Intended to Reduce Overweight and Obesity

In this submission, I would like to examine some of the elements that ought to be taken into account on policy formulation and the design of strategy directed at the reduction of overweight and obesity. As for the success of programmes that embody the implementation of such a strategy, I shall not comment, for it is a question of political will, technical competence and requisite resources.

As this is based on already well-established procedures of logical analysis and synthesis, I shall not burden my potential readers with outside references. My argument is based on two basic assumptions, on which there is a general agreement, viz., unless one suffers from a certain type of metabolic disorder, being overweight or obese is due to the inappropriateness of one’s eating or drinking habits.

The second assumption emphasises that other things being equal, being overweight or obese is a consequence of an individual’s own action. How important this is in combating our problem has until now not received the attention it deserves. Legal action such as high taxation on certain industrial food and beverages is merely palliative if successful, for it does not encourage a person to acquire appropriate eating and drinking habits for one’s own benefit, rather it compels one to do so in the prescriptive manner of a religion barring the sinners from sinning to enter a putative heaven.

So, the policy and strategy we are talking about, is concerned with increasing the number of people whose eating and drinking habits are appropriate. Their relevance to this end, depends on the policy maker and the strategist knowing what may justifiably said to cause inappropriate eating/drinking habits, and what legitimate means are at the disposal of the authorities to counter them. I shall try to address these two questions in turn.

Causes of Inappropriate Eating and Drinking Habits:

It is crucial to understand that these causes fall into two logically distinct categories, but some from both categories may co-occur. The first involves the situation in traditionally affluent countries, viz., affordable wholesome food and drink is available while some individuals do not take advantage of it due to several reasons. This represents inappropriate nutrition due to erroneous choice.

In the second, for a variety of reasons, an adequate supply of affordable wholesome food and drink does not obtain.  Under the circumstances,  one has no choice but to make use of what one could afford, which generally turns out to be the kind of item associated with being overweight or obese, i.e., starchy and/or fatty food. This represents inappropriate nutrition due to lack of choice.

It would be fair to say that intake of a balanced diet indicates that one’s eating and drinking habits are appropriate. However, what constitutes a balanced diet for a given individual depends on among other things, age, sex, current state of health, climate of one’s residence, nature of one’s work, etc. Moreover, there is some reason to believe that dietary balance may also have a racial determinant. Hence, it would not be possible to lay down a scientifically justifiable balanced diet having a universal validity.

However, human beings have managed to survive long without the benefit of formal scientific knowledge.  This in part, is due to the evolution of food culture among social groups, which empirically took into account what their habitat could best yield, and to achieve at least ‘a working balance’ among the available food items from animal and vegetable sources.

Therefore, it would be reasonable to suggest that  a balanced diet for a given person would have to be established with reference to one’s individual nutritional needs at a given period of time while keeping it as close as possible to the relevant food culture.

Having said that, it is possible to distinguish between two logically inseparable aspects of a balanced diet, viz., a qualitative and a quantitative one.  Please note the term qualitative as used here simply refers to the diversity among the victuals consumed. It is necessary, because one cannot always obtain all the nutrients one needs from a single source.

When one’s diet is sufficiently diverse to ensure an adequate quantitative access to the nutrients one needs,  it approaches being a balanced diet. Other things being equal, a quantitative change in any item in a balanced diet or its replacement with another having a different available quantity of the same nutrient would result in dietary imbalance.

Being overweight or obese then, is a result of dietary imbalance where the intake of certain nutrients  is excessive with respect to one’s actual needs. This excess is mainly in the intake of carbohydrates, fat or oils. If, we can agree on the discussion thus far,  we may then proceed to the possible causes of inappropriate eating and drinking habits included in the two categories described above.

Now, an obvious, yet an important point. Even if one has an easy access to all the food and drink one needs, it does not entail that one would select and partake a balanced diet. If one does so, it implies that one is willing and able to undertake those two tasks. This willingness is motivated by the belief that partaking of such a diet is desirable, hence it is of some value to oneself.

Having this belief implies the possession of prior knowledge of the value of a balanced diet, while having the ability to select a balanced diet implies the possession of a prior knowledge of what is constitutive of it. These two logically linked pieces of knowledge are not givens, and they have to be acquired through learning provided by relevant dietary education received at home or school.

1. Thus, inadequate dietary education can be an important cause of overweight or obesity. This seems to be particularly the case in affluent countries as well as among the relatively affluent in poor countries.
2. One often tends to deprecate the power of inherited  dietary habits to remain more or less unchanged even when  dietary knowledge takes into account changes in one’s energy needs, especially in affluent countries in the temperate zone. Central heating, motor transport, domestic labour-saving devices, automated blue-collar work, etc., have greatly reduced body’s daily energy usage while food intake does not seem to reflect it. The extent to which this may bring about overweight or obesity is difficult to quantify.

1. Greed had been openly acknowledged as a cause of being overweight or obese until it became fashionable to describe undesirable human behaviour in psycologistic terms.  Prior to  this unfortunate change, bringing up children  included training them to eat and drink appropriately. At present,  a considerable number of children do not receive such guidance.

Let us now consider the reasons for inadequate dietary education, the persistence of older dietary habits and lack of child guidance away from  greed.

1. Failure to incorporate dietary knowledge and local food culture into general education, while it is not imparted to people at home when they are young.
2. Failure of people to make their food intake match their real energy needs due to indifference, desire for convenience or a greater belief in questionable dietary information put forth by persuasive advertising.
3. Lack of time to prepare balanced meals, or failure to budget for an adequate supply of wholesome food, which compels one to resort to cheap unwholesome items.
4. Adults’ fear to curb greed among children owing to their belief in psycologistic accounts of the phenomenon, which cannot be confirmed or disconfirmed, hence, unscientific.

Until this point, the causes I have outlined presume an availability of an adequate supply of affordable wholesome food.  It is under used owing to lack of appropriate dietary knowledge, lack of skill in domestic management, failure to prepare suitable food due to fatigue or desire for convenience, belief that curbing childhood greed is somehow injurious, and the conditioned or acquired belief in food advertising.

Distribution of these causes of turning people overweight or obese in less affluent countries, seems to increase as their economies grow. One can easily observe there a significant reduction in the intake of traditional dishes while that of industrial food increases. It mirrors the social development in the ‘North’ with respect to the decline in food culture, dietary knowledge, and an increase in the desire for culinary convenience.

Now, we can take a closer look at the second category into which the causes of inappropriate nutrition belong. It is not only a category, but also constitutes a cause, which in turn arises owing to the following:

Low income and comparatively high prices of wholesome food.

Limited availability of wholesome food owing to:

1. Neglect of agriculture.
2. Excessive use of arable land for cash crops, raw materials for industrial food production, or other purposes.
3. Loss of arable land due to desertification, soil erosion, drying up of rivers and streams, etc.
4. Migration of small farmers and farm workers to urban centra.
5. Reduction of the number of young people willing to engage in agricultural pursuits.
6. Inadequacies in infra-structure that hinder the transport of fresh produce to end-users.
7. Price-wars initiated by large chains that has driven out small independent retailers of fresh produce who provide a greater choice.
8. Food loss in storage, transport, and through its passage through ‘sophisticated’ food systems (see http://www.fao.org/fsnforum/cfs-hlpe/node/992).

It should be noted that D, E, G and H above have become growing problems even in the affluent countries. In many of them, individual retail chains have united themselves into ‘trade groups’ where what food items are sold and at what prices, are decided among themselves. This compels the farmers to produce what traders will buy, and moreover at the prices dictated to them. This legal monopoly victimises the actual food producer and the end-user so that middlemen may benefit.

Critical Elements of Policy and Strategy:

These then are some of the causes of inappropriate nutrition that may be mitigated by effective implementation of suitable policies and strategies. Let us pair the elements crucial for their success in the order those causes have appeared in this discussion.

1. Policy: Rendering national education holistic by incorporating dietary education into the school system; public education through suitable channels.

Strategies:

Revision of school curricula

Information campaigns, projects (eg. ‘My Healthy Family Project of the EU)

1. Policy: Promote the sale of fresh produce and real competition among the vendors of food.

Strategies:

1. Tax incentives and establishment loans to independent vendors of fresh produce.
2. Higher taxes on factory made food.
3. Practical help to the establishment of food cooperatives.
4. Suppression of hidden food monopolies.
5. Banning scientifically untenable claims from food advertising.

1. Policy: Take steps to render public attitude to food and its intake as rational as possible. (unfortunately, this important issue is much deprecated)

Strategies:

1. Supplement public education with ‘cooking breaks’ by introducing shorter working hours for those who cook their own meals. This would be similar to the training breaks at the work place, but would come at the end of the day.
2. Employer sponsored cookery classes.
3. Educational measures to accept greed as a consequence of inadequate personal training rather than a mental issue.

So far, we have talked about the elements whose incorporation into policy and strategy is crucial to their success when combating being overweight or obese in an environment where availability and affordability of wholesome food is not the most important issue. We will next take a look at the policy and strategy elements necessary to achieve our objective in areas where affordable wholesome food is scarce.

However, we must bear in mind that the problems the policies and strategies outlined above are intended to address, are becoming increasingly common in developing countries. Thus, their applicability is more or less world-wide when adapted to specific local needs. Likewise, the issues arising from our second category above, are increasing their relevance for the developed countries.

1. Policy: An employment policy embodying an economy of cooperation rather than competition seems to be the only way to make wholesome food available to most at affordable prices. However, the crucial need for this economic revision is either ignored or not understood in spite of its obviousness.

Strategies:

Public debate on the incommensurability between environmental sustainability and justice on one hand, and the current economic system on the other.

1. Policy: Active promotion of small farms, market and allotment gardens, rural agriculture, etc.

Strategies:

1. Financial and technical support to practising small farmers.
2. Schemes to attract youth to agriculture as discussed previously in this forum (means of achieving this were also included in that discussion).

1. Policy: Undertake the general measures needed to create an environment necessary and favourable to produce and procure wholesome food.

Strategies:

Putting in place and regular maintenance of the requisite infra-structure.

Exclusion of food items from speculation in commodity futures.

• Improved agriculture extension services, training and  research facilities.
• Honest and open public debate on the consequences of abolishing government subsidised food production, especially with respect to those on nutrition if one has to depend on industrial farming for food. Such a discussion might compel more and more people to understand the danger of regarding food production  as a mere commercial venture.
• Steps to simplify the unnecessary complexity of many a so-called food supply chain in order to minimize food loss and unfairness to  the farmers and end-users.
• Active steps to attain harmony and congruence among all policies, particularly among those of agriculture, health, education, justice and trade.

I mentioned harmony and congruence among policies at the end, to stress the fact that its lack has often made many an otherwise sound policy unimplementable. For instance, a trade policy that encourages import/domestic production of unhealthy industry food is not congruent with a health policy intended to reduce the incidence of being overweight or obese,, while an agriculture policy that promotes the production of wholesome food is in harmony and congruent with that health policy. I think that generations of reductive thought has made most of us fail to see the obvious, viz. the purpose of a policy is to direct some authority towards enabling a group of people to attain some end that is necessary for their total well-being.

Good health is obviously an essential component of individual well-being. So, if one policy promotes it while another exerts the opposite effect, irrationality emerges. What policy makers always ought to bear in mind is what impact a new policy will  have on others known to contribute to individual well-being. Achieving this objective manifests itself as a set of policies displaying harmony and congruence.

This does not happen on its own volition, and it requires a political will sufficient to undertake not only the required change in perspective, but also bringing in personnel skilled in inter-disciplinary policy correlation so that every unit of authority will pull in the same direction, i.e. well-being of the people, be it at the local, national or the global level.

Best wishes!

Lal Manavado.

[email protected]

The Role of Trade

A yet unaddressed facet of this debate concerns the role of international trade and trade policy in promoting or preventing obesity and overweight.

Trade contributes to food security where it increases food availability. Trade liberalisation can stimulate hitherto protected local production, increase its efficiency and resilience along the food value chain, and thereby mitigate local food insecurity. In theory, even poor consumers can then better choose the diet which is best for them.

Safe but unhealthy food, whether locally produced or imported, cannot be prohibited. But eating today is not only a matter of free, informed choice. Obesity and overweight are related to trade rules in goods, services, and intellectual property. In a world of trade liberalisation and growing interdependence this interaction must be continuously reviewed.

Better and more food production is an issue here. Productivity increases along the global food chain, and global branding and partly government-sponsored market promotion also increase trade in expensive but not necessarily healthier foods. Agricultural policy space, little constrained by trade and investment agreements, allows countries to at least partly protect their farmers from foreign competitors and to enjoy bumper harvests without producer prices crashing or health problems increasing. With the help of farm subsidies and risk insurance support powerful operators from rich and from some emerging economies are now able to compete, despite higher production and transport costs, even on remote markets. They can simply offload their low-end products and food surpluses – and their obesity problems – on the world market, at virtually zero cost.

Unfettered free trade can thus increase inequalities of income and of access to healthy diets. Without accompanying measures trade may actually increase obesity and overweight.

Health considerations should therefore play a bigger role in trade policy formulation. Many measures proposed by international health experts on obesity and diets show a more or less strong correlation between the relevant trade rules and the presently available evidence on effectiveness. This is a matter of maximising benefits and minimising risks. For instance, tariff reductions for health-promoting products, or binding market access commitments for health services should thus be reviewed jointly between trade and health agencies, including their timing. On the other side, health authorities should look at the relevant trade rules when they assess the merits of a fat tax or of consumer information with a “traffic light label” showing the weight impact of certain foods. Governments should also aim at a better use of health-supporting goods and health services. This would improve efficiency of scarce resources. Finally, trade and investment rules can also enhance and facilitate a number of non-discriminatory health measures and private operator actions.

The lack of coordination both at the international and the national levels appear as a serious although surmountable problem. Several examples of trade frictions show that the lack of legally binding health and dietary standards impairs national implementation measures and makes them vulnerable to legal challenges in WTO litigation, not to mention parochial interests of junk food exporters and of inefficient local producers of unhealthy foodstuffs. This means that intergovernmental health, trade and financial agencies must improve their own governance and mutual support with the help of their member governments and of private operators – and by listening to advice from concerned citizens and from the scholarship.

From an obesity and overweight mitigation perspective most important and urgent, therefore, are better cooperation, standard-setting, and synchronisation between all concerned stakeholders, both at the national and international levels, especially in a process accompanying a rapidly progressing globalisation and trade liberalisation.

I think in relation to the obesity issues that the people concerned or the target people generally should be included in food program. So what are the causes of the overweight and obesity? And what the possible solution to this problem all over the world?

In the countries where the food is always available to the people, the consumption per person doesn't follow any rule it is in the most cases random choice this is the human rule ie that the human doesn't follow the calories low to define the food habitat.

The main cause of the obesity is the availability of the food and the worse way in using food choices so the estimation of nutritional requierement is baised.The absence of activities like sport and other way to burn the extra of calories led to the overweight with time.

Practicing sport, defining a right food regime adjusted to the personal requirement led to reduce the effect of the obesity.

At the end, in the last years, it was appeared a new discipline that is called nutrigenomics, this new science treat the ways to find the possible metabolic and genetics causes and solution to the obesity.

English translation below

¿Cuáles políticas y/o programas para la prevención del sobrepeso y la obesidad se han implementado en su país o región? 

Nosotros en el INTA, hemos implementado y evaluado varias estrategias de prevención de obesidad en los últimos 14 años (están publicadas). Comenzamos en Casablanca por 3 años en los temas de entregar a estudiantes de 1° a 7° básico contenidos de alimentación saludable y duplicar el tiempo destinado a clases de EF. Los resultados fueron muy exitosos mientras supervisamos la implementación, sin embargo no hubo sustentabilidad (sin apoyo de las autoridades para continuar) y se revirtieron los resultados. Después en los colegios de Macul y Ñuñoa implementamos un programa desde PK a 4° B. El Macul disminuyó levemente la obesidad, mientras que en Ñuñoa se mantuvo. En los colegios controles, hubo un aumento en ambas comunas. Adjunto un resumen presentado en un Congreso.

2. De las políticas y/o programas mencionados anteriormente, ¿cuáles han sido efectivos en cuanto a la reducción de los niveles de sobrepeso y obesidad?Complementar su respuesta con las siguientes sub-preguntas:

¿Cómo se evaluaron los resultados y/o se determinó la efectividad?

Antropometría y variables de condición física como variables primarias y conocimientos, grado de implementación y otras como variables secundarias

¿Cuáles fueron los factores de éxito que contribuyeron a la efectividad de estas estrategias?

Que la intervención sea aceptada por la comunidad educativa completa y los apoderados y que permitan una supervisión efectiva del proceso 

¿Cuáles fueron los principales retos, limitaciones y lecciones aprendidas?

Tener que convencer a la comunidad escolar y los padres que cambien hábitos. Es muy distinto saber que actuar.  

3. Finalmente, ¿Qué ELEMENTOS SON CRUCIALES para apoyar efectivamente políticas, estrategias y/o programas dirigidos a la prevención del sobrepeso y la obesidad?

Considerar elementos a nivel de gobernanza, recursos, desarrollo de capacidades, mecanismos de coordinación, liderazgo, redes de intercambio de información, entre otros.

Idealmente, debiera haber una acción coordinada de todos los involucrados (stakeholders), es decir el ambiente, kiosco, colaciones, carritos fuera del colegio, celebraciones etc. Ojalá los supermercados colaboren los más espacio y ofertas para productos saludables. Lo último es que mientras no haya " accountability" por los resultados (medidos por externos) no se van a ver cambios significativos 

Which policies and/or programmes have been implemented in your country or region to prevent overweight and obesity?

 At INTA we have implemented and assessed several strategies to prevent obesity in the last 14 years. These strategies have been published. We started in Casablanca, training pupils attending primary grades 1 to 7 in healthy food, and duplicating the time allocated to physical education classes. We had excellent results whilst we monitored the implementation of this program. However, without the necessary support from the authorities, the program was no longer sustainable and the results worsened. Afterwards, we implemented a program in the Macul and Ñuñoa schools, aimed at pupils attending kindergarten to grade 4B. Obesity decreased slightly in Macul and remained unchanged in Nuñoa. However, it increased in both communities where the target schools are located. Kindly find attached a summary presented at a congress. 

1. Which of the policies and/or programmes mentioned before have succeeded in reducing overweight and obesity levels? Please complete your answer answering the following queries: 

In which way were results assessed and/or effectiveness determined? 

Using anthropometry and physical condition factors such as primary variables and knowledge, level of implementation and secondary variables.

What were the success factors that contributed to the effectiveness?

The intervention must be accepted by the entire education community and the proxies, and they must enable an effective monitoring of the process.

What were the main challenges, constraints and lessons learned?

Having to convince the school community and parents to change their habits. Theory is one thing and practice is another. 

1. Finally, which ELEMENTS ARE CRUCIAL to effectively support policies, strategies and/or programs targeting overweight and obesity reduction?

Please consider elements regarding governance, resources, capacity building, coordination mechanisms, leadership, or information exchange networks, among others.

Ideally, the coordinated action of all the stakeholders is required (i.e. environment, refreshment stands, collations, snack carts outside school, celebrations etc). I hope supermarkets will collaborate expanding the available space and related offers for healthy products. Finally, as long as there is no accountability for the results (measured by external parties) there will be no significant changes. 

English translation below

En nuestros países hay buenas intenciones al respecto, pero hay varios factores que condicionan la efectividad de las políticas y programas, entre ellas están:

a) en el campo educativo, algunos centros educativos no toman conciencia de estos problemas, le dan prioridad a las necesidades materiales de las escuelas;

b) el consumismo de alimentos alimentos procesados y de fácil adquisición prevalece en las comunidades;

c) la mayoría de padres y madres de familia carecen de educación en materia de seguridad alimentaria.

Considero que algunos programas de alimentación escolar contribuye en cierta medida a formar hábitos saludables de alimentación. Hay que profundizar más en educar a toda la comunidad y hacer conciencia en la comunidad ampliada.

Our countries have shown good will with these issues. However, there are several factors conditioning the effectiveness of their policies and programmes. Among others:

a) In education, some schools are not aware of these issues and prioritise material needs;

b) In communities, the consumption of affordable processed food is prevalent;

c) Most parents have not been educated in food security.

I believe several school feeding programs contribute to some extent to the creation of healthy eating habits. We must strengthen education and raise awareness in the entire community.

Is it possible to make prevention and reduce health spending?

Increasing physical activity would improve the health of the Country, would reduce health spending, it would give new opportunities to work and maybe a small step forward in the field of security. Is it so difficult?

In 2016, the estimated Italian Public Health spending will reach 113.2 billion euro, 1.9% increase if compared to 2015. In 2012 it was 111 billion, equivalent to 7% of GDP (about 1,867 euro per year per inhabitant). Health expenditure is growing but, news of these days, in Italy the average duration of life, even if only slightly, is coming down.

Does it mean that, despite the huge professional and financial commitment, the resources are badly or not adequately employed, or is it just the result of the increase in costs? In any case, although much lower than that of other major European countries, it is necessary to find new ways to reduce health care spending.

The linear cuts made until now were strongly, and rightly, disputed because they do not guarantee an improvement of health; indeed, they are likely to worsen the resulting further increase in costs. It is, in fact, necessary to start a path to appropriateness, but this cannot be just a term; we need a strategy shared with health stakeholders.

The great effort that Public Health is doing, however, is aimed primarily at those who are already ill and thus require appropriate care; it is therefore difficult to reduce the spending commitment. The Italian Parliament is facing with an important institutional dilemma: on the one hand, the right to health, enshrined in the Constitution, and the consequent decision to provide free (or almost) healthcare; on the other, the imperative to contain expenses that tend to rise, even for the progressive aging of the population, which erodes great resources that could be allocated to the Social State and/or other productive investments.

Prevention is certainly the best way to rationalize spending and thus reduce it; but we all know that proper prevention can give long-term results, although it certainly leads to a substantial savings, at present risks only to be a cost; and resources seem exhausted.

It is, therefore, necessary to decide whether to run after the disease trying to patch the most damage created by it, spending as little as possible or, rather, do some investment, perhaps in new technologies, especially diagnostics, to reduce the occurrence of disease.

Or, more simply, to try to get less sick.

It is not a utopia. It is possible to get less sick thus reducing health spending. Let's see how.

Physical inactivity is a health risk, because it produces 2 million deaths / year worldwide. In particular, physical inactivity favors the 10-16% of cases of breast cancer, colon cancer and diabetes and 22% of heart attacks.

Regular physical activity is thus critical for prevention.

The health benefits brought by the change in lifestyle habits are proven by a 25-year study in which it was shown that the change in lifestyle has reduced deaths from cardiovascular disease (-68%), stroke (-73% ), cancer (-44%).

A more active lifestyle would lead to the prevention of at least 2 million premature deaths and 20 million DALYs (Disability-Adjusted Life Year) in the world.

For five diseases it has been proven the relationship between physical activity and health benefits: cardiovascular disease, stroke, colon cancer, type II breast cancer and diabetes. An expanded list of diseases caused by sedentary lifestyle includes: overweight, obesity, diabetes type II, cardiovascular disorders (heart attack, myocardial infarction, stroke, heart failure, high blood pressure, venous insufficiency), osteoporosis, arthritis, increased blood cholesterol and triglyceride levels, colon and breast cancer. All diseases that, once arisen, tend to become chronic and must be kept under constant health control and appropriate care.

It was calculated that increasing only by 1% of the number of active people, the save in health care spending would be 80 million euro per year.

The main consequence of physical inactivity is overweight and later obesity. In particular, the central type obesity, with the accumulation of fat in internal organs, is associated with an increased incidence of complications: metabolic (diabetes and / or intolerance to carbohydrates, dyslipidemia, hyperuricemia), cardiovascular (blood pressure, heart disease and ischemic heart failure), systemic (arthritis, colon cancer, respiratory failure, cholelithiasis, etc.).

About 50% of obese children over 6 years become obese at adult age in comparison (10%) of non-obese children at the same age. In obese adolescents, this percentage rises to 70% and above 80% if one parent is obese.

In Italy, 33.1% of the population is overweight (41% of men and 25.7% women), and 9.7% is obese. Although the latest figures are mildly encouraging, the levels of overweight and obesity in childhood remain high.

The phenomenon is more widespread in the South (Abruzzo, Molise, Campania, Puglia and Basilicata regions cover more than 40% of the sample), where some eating habits and poor perception of the phenomenon are a problem. Out of 46,492 children from 2,623 classes of third grade, 22.1% of children aged 8-9 years are overweight compared to 23.2% in 2008/09 (-1.1%) and 10.2% in condition of obesity, compared with 12% in 2008/09 (- 1.8%).

The presence of obesity in adolescence is predictive of a greater development of cardiovascular events in adulthood, although in this age of life a normal body weight has reached. Children between 6 and 11 years with overweight problems are one million one hundred thousand. 12% are obese, while 24% are overweight: more than one in three children, therefore, has a weight higher than it should have for his age.

How did we come to this?

School medicine and military medicine have been virtually dismantled, with serious impairment of prevention. The early detection of many diseases slows the onset of complications and contributes greatly to improving the quality of life; an example among all: diabetes, which affects a large number of people with increasing costs.

Physical activity is important for the prevention of many diseases and to improve the conditions of sick people. "Exercise is medicine" is the new address for prevention and therapy.

The boys also benefit of the sport activity for their psychological maturation.

In addition, there are the damage from poor nutrition, alcohol dependence and the overuse of pharmacologically active substances, misuse of drugs, even those permitted.

It is therefore necessary to increase the quantity / quality of time devoted to physical activity, both at school and outside school, but above all, it is vital the dissemination of knowledge of the problem.

A widespread information / training, along with a sport and proper medical supervision into every type of school, would lead to a sharp reduction in public spending, much higher than the 80 million of which we have just spoken, with an almost negligible investment.

The ideal would be to set up in School a course of education to health, with the principles of nutrition and physical activity, in order to improve the lifestyles and reduce health spending through health education, proper nutrition and sports activities. 1-2 hours a week would be enough to communicate to children, and indirectly their families and the families of the future, what are the criteria for a healthy life.

It is, however, necessary to have suitably qualified teachers for the treatment and dissemination of health prevention principles of proper nutrition and the correct approach to sports activities. A specific training should be therefore held in the University. Health education cannot be done by the science teachers or those of motor sciences, alone; they must have a physician specially trained to coordinate, perhaps in co-presence, the interventions.

We must start a comprehensive training: school teachers, family physicians, those involved in physical training and athletics, sports administrators. One might ask, why sports managers? Because are needed sports managers who are not motivated only obtaining the results, but they do of sport a means to improving public health, as described below.

How to increase the number of practicing physical activity? We should promote agreements between schools and sports facilities (whereas schools do not already have) belonging to municipalities, sports clubs, for two / three hours in the afternoon, for all the kids of middle school at least and high school, asking to families a minimum contribution, such as 20 euro per month in order to perform physical activities at a low cost.

If we imagine to gather in a sports facility 100 boys, whose families paying 20 euro, with the 2,000 euro resulting it can be payd a qualified instructor who would follow them for the two / three hours, leading them to a controlled physical activity. As with all sports, kids should undergo a preliminary medical examination, which would identify any eventual disease.

So, in a very simple way, it would reduce obesity and the diseases related to it, it would improve the course of many diseases, it would increase employment and you could have a very large sports lever, at almost null cost.

Someone might object: but if some students do not want to exercise? No problem, they would also go to the fields, where they will attend the activities of others. Sooner or later they will be convinced to do it too.

I mentioned the sports administrators. It is fundamental a preparation of adequate university level also for those who want to pursue a sports manager career. At all levels. The ideal sports manager must have some knowledge in several fields, from the biomedical one to the technical, training, rehabilitation, but also legal and economic, psychology of sport and sports communication, plant and equipment. Not always it is enough to have been an athlete, even if of high level, to be a good sports manager.

For the younger generation, which should be addressed at a proper sports culture, the presence of instructors and managers who have a clear knowledge of what they do and of the human material they have in their hands.

As an example, some time ago it was proposed that it should not be necessary the license to coach amateur teams, to save money. But we know how important a coach in a team, his role as an educator and controller; according to the proposal, it could be anyone. But with what kind of results?

In the concept of global education it must also be considered the possible positive effects towards public safety, in that many criminal organizations are using sports centers for the sale of illegal products and for money laundering.

The illicit is favored by underdevelopment and ignorance.

The institution, in each sports center from the smallest to the largest organization, of the certified quality of the manager and / or trainers, would constitute not only a guarantee for the public to have quality instructors, but also the possibility of  fully "tracking" the system, by limiting the range of action of criminal organizations.

Obviously, in universities or in hospitals, should be developed specific routes for either the sports fitness, or recovery from diseases as well as for the diagnosis and treatment of diseases related to the sport.

The problem of physical activity, however, does not invest only the children but also the elderly. The exercise is a powerful stimulus for the production of GH and, on the other hand, aging and obesity are associated with a reduction in the production of GH. But then, is obesity which is growing old or aging that makes you fat?

The infiltration of fat is a natural part of the aging process. As we become old, our muscles gradually begin to shrink, burning fewer calories. When we lose muscle tissue, we burn less fat and start to add fat to our structure.

Therefore, if it is physiological that the fatty tissue replaces the muscle during the age, it is essential to keep active the muscular system, to delay the process and avoid the excess of fat accumulation.

In short: increasing physical activity would improve the health of the Country, would reduce health spending, would give new opportunities of employment and maybe also a small step forward in the field of security.

Is it so difficult?

Prof. Roberto Verna

Professor of Clinical Pathology

Director of the Center for Medicine and Sport Management

Sapienza University of Rome, Department of Experimental Medicine

Past President of the Italian Society of Clinical Pathology and Laboratory Medicine - SIPMeL

iPresident, World Association of Societies of Pathology and Laboratory Medicine

and the WHO Representative

President, World Pathology Foundation

Human behavior is extremely complex, e.g. one man's trash is somebody elses treasure. Hence, the need to understand all the driving factors behind over-eating before overweight becomes a vicious downward spiral e.g., tired to exercise> more anxious > eating). Addressing the symptoms will only delay the solution and thus aggravate the problem!

In Ecuador the government implemented a food "traffic light" with red for high sugars, fat and salt, yellow for medium and green for low. The consequences were desastrous, to say the least, people lower their consumption of milk, yougurt and other healthy foods while continue eating processed foods with plnety of MSG (Mono Sodium Glutamate) as well as other preservatives and additives which were completely ignored by the infamous food "traffic light".

1. Which policies and/or programmes have been implemented in your country or region to prevent overweight and obesity?

• Mexico is probably one of the most active countries in Latinamerica in setting anti-obesity public policies. For example the ANSA (National Agreement for Alimentary Health) since 2010, the consequent "Code for self-regulation in publicity of food and drinks targeted to children" (Codigo PABI in Spanish)  and most recently, the famous Mexican sugary drinks tax.

1. Which of the policies and/or programmes mentioned before have succeeded in reducing overweight and obesity levels? Please complete your answer answering the following queries:

• What was the target population?

Most of the strategies have aimed to the general population but there has been a special emphasis on children, for both ethical and economical reasons, i.e. these strategies are more cost-effective by its own nature than those aimed to adults, simply because the duration of the positive effects is expected to last longer. Additionally, children's preferences are thought to be more modifiable than those from the adult populations.

• In which way were results assessed and/or effectiveness determined? What were the success factors that contributed to the effectiveness?

Generally speaking, the epidemiological data -overweight and obesity prevalence- is the one used to determine the success of the strategies. However, in the case of the sugary drink tax, the emphasis has been on economical data reflecting household expenditure and beverages sales. In my opinion, there is no way to account any of this strategies as a success. There is no way yet to link the economical data to the epidemic data.

• What were the main challenges, constraints and lessons learned?

The National Public Health Institute (INSP) has published a preliminary report  stating that the tax has decreased sugary drinks consumption specially among the poorest. A few months later, a new report was published confirming this data. Logically, the tax supporters used the INSP message as evidence to state that the sugar tax is a significant success. 

However, the study itself mentions a very interesting fact that curiously enough, has been absent in all the related public communications from the INSP: The household expenditure has not decreased accordingly. There is no savings from the families, and this fact cannot be attribuited to replacing taxed sugary drinks with bottled water. 

In another study by some of the researchers involved in the INSP study, it is described how the industry has reacted and adapted its strategies to the taxation. Actually both studies conclude that more research is needed in order to find out if the sugary drinks tax is really working or not. 

So, if the goal of the tax was somehow to minish the sales of sugary drinks, it may have been succesful. However, if the goal of the tax was to reduce overweight and obesity, there is no evidence to conclude anything. As I state it in the Iberoamerican Development Bank's blog, a reduction in sugary drink consumption does not necessarily mean obesity reduction. Thinking in such a linear way causes to overlook that people may be substituting these products with other equally harming, specially if we consider the possibility of a compensation behavior derived from a "halo effect". That means that some people giving up a sugary drink, e.g. having a healthy-imposed-behavior, may think they are entitled to having an extra dessert because they are being healthy anyway...In addition, having an extra dessert, could trigger the "what the hell effect", which is a temporary lost of control. This could end up in people having not an extra dessert but having several extra treats during the day, possibly explaining the lack of savings by giving up a sugary drink. 

Of course, it could be also simpler. People could be substituting the now more expensive sugary drinks by cheaper treats or products. Specially under the reaction of the food and beverages industry.

1. Finally, which ELEMENTS ARE CRUCIAL to effectively support policies, strategies and/or programs targeting overweight and obesity reduction?

• ​First of all, we must revise the cause of obesity. The calorie balance concept cannot be used to explain fat generation (or adipogenesis) wihtout risking inefficiency and redundancy. If we do not know what really causes obesity we cannot create efficient strategies. We will spend thousands of resources treating the symptoms and possibly reinforcing the causes. I am currently working in a discussion paper in this matter, explaining why calorie balance is not useful and what could we do instead of using it. If somebody is interested, we can discuss it further. 
• We have to take in consideration people's behavior, biases and particular heuristics in every policy or intervention
• we have to try to forecast the consequences of the public policies from the main stakeholders and reduce the risks of being undermined by their reactions
• Governments have to stop thinking in linear ways They have to notice that the whole food value chain is interconnected, from the incentives that the farmers have to plant one or another seed to what the final consumer decides to cook for dinner. 

Thanks for reading this. I look forward to hearing back from you.

Salvador