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.
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power point presentation of Clinical evaluation of strabismus
Specific policies to tackle diet-related NCD in Europe
1. 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
3. 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
5. • 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
6. • 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
9. 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
10. 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
11. 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
12. 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
13. 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
14. 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
15. • 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
16. Dietary trends in Europe
- Food supply data (FAO)
- Retail sales (Euromonitor)
19. 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
20. 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
21. Dietary trends in Europe
- Food supply data (FAO)
- Retail sales (Euromonitor)
22. 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)
29. 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%
30. 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%
32. • 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 …
33. • 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
35. ‘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.’
36. 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
40. 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
41. 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
42. 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
43. 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
44. 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)
45. Garber AK, Lustig RH (2011) Is fast food addictive?
Curr Drug Abuse Rev 2011 Sep;4(3):146-62.
Habituation/
addiction
46. 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
47. 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)
48. 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
49. 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
50. • 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
52. 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
53. 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
54. 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 …
55. 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.`