Arya M. Sharma, MD

Long-time readers will recall previous posts on the environmental impact of food production and how closely the societal root causes of the obesity epidemic may be linked to global warming (in more ways than one would think).

I now came across a most interesting and remarkably comprehensive and insightful analysis of the true environmental impact of our food environment.

This document, released by the Barilla Centre for Food and Nutrition (yes, the pasta folks are involved in this), answers important questions on just how different the carbon footprint of preparing pasta depends on how much water you use to cook 500 g of pasta (assuming a ± 20% pasta/water variable ratio and 10 min cooking time).

Such, ‘light-hearted’ trivia aside, the report actually provides some amazing insights into the ‘field-to-fork’ impact of food production and how it relates to everything from environmental impact to economies of scale.

The centre piece of the report is The Double Food-Environmental Pyramid, where one pyramid represents the traditional food recommendations and the other once (upside down) represents the environmental impact of those foods.

As it turns out (not surprisingly perhaps), in general, the more recommended foods tend to have a lower impact on the environment that the foods recommended for a lower consumption.

Thus, the double pyramid exemplifies how the food pyramid actually meets two important goals -maintains people’s health and protects the environment. In other words, eating ‘healthy’ is not just good for you but also for the planet (this is somehow reminiscent of ‘passive smoking’ because suddenly what YOU eat affects MY environment and, therefore, MY health).

Rather than fascinate you with an incredible amount of highly interesting trivia in this report, I suggest you download the original document here for a most interesting Holiday read.

Buon appetito!

AMS
Edmonton, Alberta

p.s. Hat tip to Annette Anderwald for pointing me to this publication!

So on the final day of the World Diabetes Congress, I attended a debate on whether an organization like the International Diabetes Federation, should be accepting money from corporations.

The ‘in favour’ position was argued by Sir Michael Hirst from the United Kingdom, who is currently the President-Elect of IDF and will take the office of President of the Federation in 2012.

The ‘opposed’ postion was argued by John Yudkin, Chairman of the International Insulin Foundation and Emeritus Professor of the London School of Hygiene.

Hirst eloquently (and predictably) pointed to all the good that IDF does by driving the global diabetes agenda, fostering the international diabetes community, increasing diabetes awareness, engaging governments, publishing position papers and the diabetes atlas, and hosting countless roundtables, task-forces, and congresses like this one, would not be even remotely possible without strong corporate sponsorship.

As he noted, diabetes simply does not have the same appeal of infectious diseases like malaria or HIV/AIDS, which draws a flock of Hollywood celebrities, philanthropic associations (Gates Foundation), and publicity seeking politicians to throw money at the problem.

Focussing on the relationship with the pharmaceutical industry (which provides most of the corporate funding for IDF), Hirst argues that without an organization like the IDF, these companies would simply hold their own conferences and educational events - with no checks and balances - without any need for transparency or ethical standards - events would be driven solely by profit.

In contrast, with IDF in charge, it provides a credible channel, can impose checks and balances, provide and enforce an ethical framework, and clearly drive the agenda of these meetings and publications.

Thus, as was plainly evident at this (and all medical conferences I tend to go to), speakers have to publicly declare their ‘conflicts of interest’, ’sponsored symposia’ are clearly marked and declared as such, and the industry exhibits are recognizably exactly what they are - industry exhibits.

In his counterargument, Yudkin (also rather predictably) argued that although pharma companies do make and continue to develop effective treatments for diabetes, these newer treatments are often far too expensive for people in developing countries (where most people with diabetes live).

Thus, although generic insulin is listed in the WHO compendium of essential drugs and newer (more expensive) insulins have yet to prove their clinical benefits, when prescribers (read ‘doctors’) come to conferences such as this World Congress, and learn about all the latest diabetes treatments, they are far more likely to return to their countries and prescribe these expensive drugs to their patients, thereby using up more of the health care budgets in their countries than would actually be required.

Yudkin also pointed out that the 95% of IDF funding (about 8-10 million in a non-congress year) comes directly from corporate support makes up a tiny fraction (2%) of these company’s sales - so it is easy to see how every dollar spent on the IDF likely delivers 100-fold in returns to their bottom line.

Yudkin challenges the notion that Codes of Conduct or Ethical Frameworks do much to counteract corporate influence. He also notes that by accepting corporate funding, it will be impossible for IDF to demonstrate real ‘outrage’ about corporate promotion of expensive (and not necessarily more effete) drugs in these countries.

He held up the International Union Against Tuberculosis and Lung Disease as a shining (albeit only) example of a major health organization that does not accept core funding from pharma. The Union interestingly gets all of their over $50 million in annual funding from governmental developmental funds, major charitable and philanthropic foundations, and (interestingly) Big Oil (who all appear to have jumped on the infectious disease cause).

So, all in all, a very predictable debate with very predictable arguments on an issue that will likely remain as unresolved in the future as it is now.

Somewhat disappointingly, the entire debate focussed on taking money from pharma - no discussion of engaging with food companies, city builders, car manufacturers or any of the other countless industries that one would assume are both part of the problem as well as potentially parts of the solution.

In balance, I believe I am more for disclosures, codes of conduct, and transparency when engaging industry as partners to actually get something done, rather than simply waiting and hoping for governments or benevolent billionaires to step up to the plate (remember governments and billionaires also have their own ‘agendas’).

I guess there is a fine but distinct line between dancing and sleeping with a porcupine.

AMS
London, UK

In my continuing coverage from the World Diabetes Congress, I thought it may be appropriate to share with my readers the Global Diabetes Plan 2011-2012, recently released by the International Diabetes Federation.

The objectives of this ambitious plan are to

1) Improve health outcomes of people with diabetes - early diagnosis, cost effective treatment and self-management education can prevent or significantly delay devastating diabetes-related complications and save lives.

2) Prevent the development of type 2 diabetes - lifestyle interventions and socially responsible policies and market interventions within and beyond the health sector can promote healthy nutrition and physical activity and prevent diabetes.

3) Stop discrimination against people with diabetes - people with diabetes can play an important role in their own health outcomes and combating diabetes more generally. Supportive legal and policy frameworks, awareness campaigns and patient-centred services uphold the rights of people with diabetes and prevent discrimination.

The key strategy of the plan is to call on governments to implement National Diabetes Programmes - Comprehensive policy and delivery approaches enhance the organisation, quality and reach of diabetes prevention and care. It is feasible and desirable for all countries to have a national diabetes programme and successful models are already in place in some countries.

The hope is that this strategy will deliver the following results:

1) Strengthen institutional frameworks - strengthen UN and country-level leadership across multiple sectors to ensure coherent, innovative and effective global and national responses to diabetes, and achieve the best possible return on investment.

2) Integrate and optimise human resources and health services - re-orient, equip and build capacity of health systems to respond effectively to the challenge of diabetes through training and workforce devel- opment, particularly at primary care level.

3) Review and streamline supply systems - optimise the provision of essential diabetes medicines and technologies through reliable and transparent procurement and distribution systems.

4) Generate and use research evidence strategically - develop a prioritised research agenda, build research capacity and apply evidence to policy and practice.

5) Monitor, evaluate and communicate outcomes - use health information systems and robust moni- toring and evaluation to assess progress.

6) Allocate appropriate and sustainable domestic and international resources - achieve innovative, sustained and predict- able resourcing for diabetes, including Official Development Assistance (ODA) for low-and middle-income countries.

7) Adopt a whole of society approach - engage governments, the private sector and civil society (including healthcare workers, academia and people with diabetes) in working together to turn the tide on diabetes.

With regard to point 7, the report comes out very much in favour of engaging business and industry in an attempt to encourage:

- property developers to improve building design for physical activity and social inclusion.

- the food industry to support wide availability of nutritious and affordable food and bever- ages, reduce marketing of unhealthy food and to adopt socially responsible business policies and practices.

In fact, this afternoon (too late for this blog post), I will attend a debate on how such interactions with industry could work and perhaps, more specifically, whether or not an organization like the IDF (or for that matter any NGO) should accept funding from industry - including those, who may be deemed to be “part of the problem”.

As the Scientific Director and CEO of the Canadian Obesity Network, Canada’s only national non-profit organization dedicated to obesity prevention and management, which, despite enthusiastic public proclamations by health ministers on their intent to address the obesity problem, currently has no sustainable public funding, this topic is obviously of considerable interest.

I look forward to reporting, on what I hope will be an enlightening debate in tomorrow’s post.

AMS
Dubai, UAE

p.s. a copy of the IDF Global Diabetes Plan is available here

As regular readers will recall, this week I am attending the World Diabetes Congress - with well over 14,000 attendees, the largest ever world congress on this issue.

For readers, who are not familiar with the International Diabetes Federation (!DF), it may be worth pointing out that the IDF is an umbrella organization of over 200 national diabetes associations in over 160 countries. IDF’s national diabetes associations are divided into the following regions: Africa (AFR),Europe (EUR),Middle East and North Africa (MENA), North America and Caribbean (NAC),South and Central America (SACA), South East Asia (SEA) and Western Pacific (WP).

Thus, the IDF, which has been in operation since 1950, represents the interests of the growing number of people with diabetes and those at risk.

The mission of IDF is to:

“advance diabetes care, prevention and a cure worldwide.”

Its strategic goals are to:

Drive change at all levels, from local to global, to prevent diabetes and increase access to essential medicines.

Develop and encourage best practice in diabetes policy, management and education.

Advance diabetes treatment, prevention and cure through scientific research.

Advance and protect the rights of people with diabetes, and combat discrimination.

(interestingly, these goals are reminiscent of those of the Canadian Obesity Network, Canada’s National Obesity organization, with the difference perhaps that obesity is a much larger issue than just diabetes).

Amongst the many activities and resources provided by the IDF, one that readers may find of particular interest (and one that can be a great time waster for readers who are looking for new ways to procrastinate) is the interactive World Diabetes Atlas, now in its 5th edition (just released last month).

The atlas exemplifies just how many folks around the work (especially in South Asia) are affected by type 2 diabetes - interesting, an obesity map of the world would look almost identical, except that the numbers would be far greater (only about 15-20% of obese people actually go on to develop diabetes - but may well have other weight-related health problems).

One of the notable features of this congress is the massive industry exhibit - not quite as extensive as those at cardiology or oncology meetings but, by a significant magnitude of scale, larger than any industry exhibits seen at obesity meetings. This is of course because diabetes management (although never curative) is big business, with countless new classes of anti-diabetic drugs in the pharma pipelines to add to the many oral and injectable treatments that are already out there (not to mention the vast blood glucose monitoring and insulin pump industries).

While there is no doubt that these companies are providing excellent products and services that make the life of people with diabetes so much easier and help reduce the horrible risks of this condition, one can only wish that in the not too distant future, a similar arsenal of treatments and management tools may become available for those struggling with obesity and its myriad sequelae (EOSS 2-4).

While the hope is not to ‘cure’ obesity (I am not sure we can actually do that), having effective obesity treatments that fill the vast therapeutic gap between ‘eat-less-move-more’ and bariatric surgery are urgently needed.

Not only would this reduce the global burden of diabetes but hopefully also the global burden of the over 20 other chronic conditions that are strongly associated with excess weight (including many cancers).

Unfortunately, neither the current regulatory framework for new launching new obesity medications nor the necessary investment into training health professionals to better manage obesity or into research to find better treatments comes close to the actual size of the problem (just count how many Canadian medical schools actually have a chair in obesity - I know of two).

So although there is an appreciable number of talks and sessions on obesity (including the ones the I am giving and chairing), the focus of this congress is of course on managing diabetes and its complications.

Unfortunately, as I have said before, managing type 2 diabetes without addressing obesity is largely ‘palliative’ care.

Obviously, not a popular view at this conference.

AMS,
Dubai, UAE

Although many initiatives on preventing obesity aim to change individual behaviour, the reasons driving these behaviours (insofar that these are not directly attributable to biological or psychological issues) can no doubt be found in the ‘obesogenic’ environment that surounds us.

How this obesogenic environment is, in part, attributable to ‘globalization’ and how approaches that go well beyond educating or targeting individuals will need to be considered to improve population health (rather than just obesity), is the topic of an editorial by Kim Raine, University of Alberta (and Chair of the Canadian Obesity Network’s Science Committee), published in the International Journal of Public Health.

Given the rising obesity rates in emerging economies around the globe, Raine asks,

“Are emerging epidemics inevitable, or have we learned lessons that may help prevent developing countries from suffering our fate?“

As Raine points out, the determinants of obesity include individual behavioral determinants (diet and physical inactivity), environmental determinants (e.g., economic access to healthy food and physical activity opportunities) as the context for behavior and social determinants (cultural, economic and political) that function at societal levels.

Yet, the first line of defense in public health often emphasizes educating individuals on the importance of maintaining a health lifestyle, when in fact the experience for from industrialized nations actually suggests that a focus on individual behavior change is insufficient to stem the rising tide of obesity. Rather, it appears essential to address the “upstream” environmental and social determinants of diet and activity behaviours.

Thus, instead of focusing on changing peoples behaviours through education, it is perhaps important to note that (as stated by Swinburn)

“Obesity is the result of people responding normally to the obesogenic environments they find themselves in. Support for individuals to counteract obesogenic environments will continue to be important, but the priority should be for policies to reverse the obesogenic nature of these environments”.

Thus, an ‘ecological perspective’ on the obesity crisis suggests that efforts must influence policy to create opportunities for social and cultural change and address the social, economic and cultural determinants of obesity.

As Raine writes:

“The urgency of shifting the intervention focus upstream to reverse the obesity epidemic poses a significant public health challenge to local, national and global organizations. Addressing the root causes, or drivers, of obesity means confronting and regulating a globalized economic system that promotes growth and consumption, including a food system that profits from expanding markets and promoting energy-dense products.”

Unfortunately, as I have noted before, changing such social and environmental drivers of obesity at a policy level may have to go well beyond simply making this a matter of ‘diet and exercise’.

Thus, simply calling for populistic ‘quick-fix’ policies, which focus on making us “eat less and move more”, an approach that has proven so ineffective at the individual level, is likely to remain as ineffective at the population level, unless we address the key societal values and norms that lead to such policies.

As I have previously declared, ’shame, blame, ban and tax’ approaches, that may have worked well for tobacco, are very unlikely to work for obesity (how exactly would you tax someone into feeling better about themselves, getting more restorative sleep or lowering their emotional stress levels?).

Indeed, such a policy discussion would likely need to be prefaced by a fundamental societal discourse on what we value as individuals and as social beings - everything from how we make and spend our money, raise our kids, build and nurture relationships, and find spiritual meaning, purpose and balance in our lives would likely have to be ‘open game’ for discussion.

Are we really ready for that?

AMS
Toronto, Ontario

Raine KD (2011). Obesity epidemics: inevitable outcome of globalization or preventable public health challenge? International journal of public health PMID: 22075687