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The global nutrition transition describes how societies shift from patterns of undernutrition (stunting, micronutrient deficiencies) to overnutrition (obesity, diabetes, hypertension) as they develop economically, creating a 'double burden' where both conditions coexist within the same populations, households, and even individuals; this transition is driven by increasing life expectancy, urbanization, rising household income, economic globalization, and unhealthy lifestyle changes, with biological mismatches between our evolutionary preferences for sweet, fatty, and calorie-dense foods and modern environments that make unhealthy foods abundant, cheap, and easily accessible, requiring multi-level interventions across individual, household, community, and policy levels to address these interconnected challenges.
Food Systems and Global Health: The Double Burden of Malnutrition and Obesity
Added:Even this, yeah.
[LAUGH] It's kind of crazy.
[COUGH] Hi everyone. Welcome to Edible Education today.
Today we have a lot of really great Speakers.
First before class actually starts, we are very lucky to have two people from the prevent cruelty initiative.
And that's happening here in California.
So from before class starts I would like to introduce you to a few very great people, Patty Northcut, [LAUGH] >> [APPLAUSE] >> And Lydia Chow.
[APPLAUSE] Hi, so Lydia and I are working with Prevent Cruelty California on a November 2018 ballot initiative.
That would end the extreme confinement of three species of factory farm animals.
That are currently kept in tiny cages so small that they can't move.
And Prevent Cruelty California is a coalition of organizations including the Humane Society, Animal Legal Defense Fund, the Mercy for Animals, the Humane League and I see a lot more.
And Lydia's gonna talk to you a little bit more about the confinement that these animals go through. >> Thanks, Patsy.
Yeah, so you know this is a whole course about food So you may have already heard what I'm about to say.
But there are more than 9 billion land animals, now, currently trapped in factory farms, raised for food, in the US.
And there is, surprisingly, even now, almost no federal legislation that works to give them more humane conditions in their living.
Aside some relatively small measures that apply to transportation and slaughter.
And even those don't apply to birds.
Chickens, which are the vast majority of that nine plus billion animals.
This legislation for prevent for Prevent Cruelty California would enable these animals, that is, veal calves, breeding pigs, and egg-laying hens.
To at the minimum have the room to spread their wings or spread their limbs, stand up, turn around.
Many, really most of them, can't really do that right now, so I'm very passionate about this.
I think it's groundbreaking legislation.
If it gets on the ballot I know it's gonna be voted on and I'm really supportive of it. >> And the Guardian, we were on the front page of the Guardian a week ago on March seventh.
And this article right here the headline kind of says it all.
It's a history in the making.
California aims for the world's highest farm animal welfare law.
The new law would ban the sale of all eggs, pork, or veal from a caged animal putting the state ahead of the EU.
If campaigners can get enough signatures, so that's our challenge right now.
And the real leverage of this law is that it not only applies to everything in California, but everything sold into California.
And Calfornia's the sixth biggest economy in the world, so it has a lot of leverage in states.
That wouldn't otherwise put an initiative like this on their ballot for the voters to decide.
So I thought I'd just kind of briefly touch on what a ballot initiative is for anybody who might not already know.
Basically, it's the most direct way that everyday citizens can enact change.
It's a paper petition, not an online petition.
Signed by a certain number of registered voters that can bring by about a public vote to create a local laws in California.
And we are one of 24 states that allow this.
You wanna talk about? >> Sure, a question that comes up because I've been collecting signatures for this for months is will this effect the cost of food?
Cost increases are expected to be minimal to non existent.
Maybe a penny or two on eggs and there's not gonna be any tax to support his at all.
So, its, again it is something, it's a measure that's gonna really improve our food system.
For people, for animals, for the environment cuz remember this increases food safety as well.
Overcrowded animals lead to more cases of salmonella, etc., when they're all crammed into cages together. >> So I wanna just touch base briefly on if this calls to any of you, we have until April 23rd to get all of our signatures.
And there's several ways that you all can be involved.
And this video here is the homepage, on the homepage of the website.
And so to just give you a tiny overview, wait, go. >> Hey you, want to help end some of the worst forms of factory farm cruelty?
If you live in California this is your chance to make a big difference.
Right now, Animals in factory farms are routinely crammed inside cages so small they can barely move an inch for nearly their entire lives.
But a historic ballot initiative could change that forever.
The California Prevention of Cruelty to Farm Animals Act would ban the production and sale of products made from animals kept in these cruel cages for good.
That's where you come in.
To get this measure up for a vote, we need to get more than half a million signatures from California voters. >> If this issue calls to you, there's three things you can do as you're leaving class.
We're going to have five of us on either exit getting those signatures. >> And it really just takes a minute to stop and Sign if you are registered voter.
So it would be wonderful all of you signed if it calls to you.
And then if it really calls to you then you could actually join us in getting signatures.
Chris Wynn is actually gonna be here and he's gonna be up top and he's featured in the Guardian article.
He's like our best signature gatherer and he's like this adventure king that goes on these great signature gathering adventures.
And you all could join him if you wanted to.
We highly recommend it.
And then the third thing you could do is if you have ideas for ways for us to talk to other classes to get lots of people involved.
Please let us know, my email address is Patsy Preventcrueltyca.com.
So you can just send me an email.
I'll connect you and you can sign up together.
You can learn more about all of this online at preventcrueltyca.com.
And the valid initiatives up there are lots of information.
And if you want a packet sent to you you could have it sent to you, or we can also give you one here after.
Thanks a lot for considering, yeah. >> [APPLAUSE] >> Thank you so much.
Now we also have someone who's gonna lead class today.
Professor Rosenwag is out of town and there's a lady who, a woman, who really leads this class behind the scenes.
Her name is Hannah Love and she's been such a force behind this class for so many years.
She works on the edible schoolyard side of the class so let's all give her a really warm welcome. >> [APPLAUSE] Thanks, Verhini.
I am usually behind the scenes, so it's a pleasure to step in for Professor Rosenzweig tonight.
But I'm a little out of my element, so bear with me.
Welcome to Class Nine of our Edible Education lecture series on understanding the food system.
And I wanted to mention really quickly, before we get into introducing our speakers, that we're gonna take attendance at the end of class tonight, not now.
We're gonna wait until the end.
So once we're done with the Q&A, stick around if you wanna get counted.
Last week, you remember we had Paul Hock in here, talking about his wonderful, kind of inspiring project Drawdown and the work of his newly published book by the same title.
I know a lot of us found his presentation really inspiring and very solutions-oriented for the future.
And thinking about climate change and kind of the systems that we already have at our fingertips for making some pretty incredible changes going ahead, so that was inspiring.
And tonight we are really fortunate to have Dr. Leah Fernald and Wendy Gosleiner here.
They are going to sort of give us some perspectives on food and nutrition through the public health lens, both internationally and locally together.
Their perspective is really rich.
And I know you guys work together, so that's a really lovely thing.
So we welcome you both.
Dr. Leah Fernald, I'm just gonna say a little bit about you both and read it cuz I don't have it memorized.
Is director of Public Health Nutrition and professor in the Community Health Sciences here at Berkeley's School of Public Health.
She's a respected expert in global health, working at the intersection of human development, nutrition, and policy.
Her work over the last 20 years has focused specifically on infants and children in low income and middle income countries, with the overarching goal of improving lives of vulnerable children through innovative interventions.
And Wendy Gosleiner is a doctor of public health and a registered dietician.
She's a project scientist with UC's Nutrition Policy Institute in the division of Ag and Natural Resources.
You're based here in Berkeley though, right, yeah.
She has dedicated her career to understanding, teaching about, and working to improve policies and programs that affect population health and nutrition.
With a focus on eliminating health disparities and improving federal food and nutrition programs.
Please give them both a warm welcome.
>> [APPLAUSE] >> Thank you. >> So much. >> Yeah.
>> I'll give you a time check. >> Great.
>> You're gonna start with pi or start with. >> First of all, we wanna wish you all, Happy Pi Day. >> [LAUGH] >> So we have as an ice breaker activity, does anybody know more than three digits of pi?
Cuz we have prizes, two prizes for the top number of digits of pi.
Who's ready to go?
I have two pies here, [LAUGH] which are prizes for the top number of digits, and Wendy has the actual digits right here.
Who's ready?
All right, we have two prizes, so really, come on down and recite pi.
Who's ready?
All right, here we go, here he comes, all right.
We've got two, this is perfect. >> Okay.
>> [LAUGH] Hey, you got two mics.
>> Two mics, we're gonna do this together and see who goes the longest.
What do you think?
Is that crazy?
All right, let's just try this.
And go.
>> 3.1415926535897932384626433832795- >> Are they winning, you guys, or what?
Yes, raise your pi. >> [APPLAUSE] >> [LAUGH] >> Nice work, all right.
[LAUGH] >> Nicely done.
>> That was amazing.
>> [LAUGH] >> We didn't even get, you printed out how many? >> 1,000 digits.
>> I did have up to 2,000- >> [LAUGH] >> Who's counting?
And the other thing before we talked to you, we just wanted to make sure we know a little bit about who you all are.
And there are too many of you for us to go one by one, but raise your hand if you are students in the Business School, great.
Okay, and how about in Public Health?
Psychology?
Uh-huh, Maths?
We have a couple, other sciences, biology, physics, chemistry?
Okay, nutrition science? >> Environment, did somebody say environment? >> Environment, natural resources.
Thank you, okay, what did we miss? >> What are we missing?
>> Did we miss any big groups?
How many of you are undergraduate students?
Okay, a lot of you.
How many of you are graduate students?
And how many of you are community members?
Great, fantastic. >> Nice to see you all.
>> Well, we're really excited to talk to you all tonight. >> Right, so we are going to each talk for about half an hour.
I'll start with the global perspective.
And then when people talk about the United States, so there are times here when I'm gonna ask for your input, I'm gonna ask you a question.
So, I realize it's a little tricky because of the microphone placement, but if you can shout out answers, I'm happy to repeat those into the mic, so everyone can hear.
So I'm gonna talk about the global paradox of malnutrition and obesity.
So you may be aware that 6 million children die every year from under-nutrition, from completely preventable causes.
You may be aware that 1 billion people on the planet are overweight or obese.
What you may not know is that these things are happening in the same countries, the same households, and in some cases, in the same children, who are stunted, which is a sign of under-nutrition, and obese, which is a sign of over-nutrition.
So, we have what we call the nutrition transition, which is really this evolution of epidemiologic transition, a demographic transition, all of which then manifests as a nutrition transition.
In which we have the prevalence of diseases related to poverty, poor water, poor sanitation, then also transitioning to being diseases of obesity, diabetes, hypertension.
So the nutrition transition technically is this decrease in prevalence of underweight and under-nutrition, and an increase in the noncommunicable chronic diseases.
And what you can see here, which I'm gonna try to read backwards [LAUGH] so I can make sure to show you.
Cuz I can't see this without looking at it.
These are the stages of nutrition transition.
Here we go, perfect, thank you.
I won't stand here the whole time.
So let's start at the far left.
So this is the hunter-gatherers, this is where the hunter-gatherers are.
You can see the consumption patterns, wild plants and animals, the very labor-intensive lifestyle.
These are lean, robust high disease rate, but low fertility and pretty low life expectancy.
Then we get to pattern two, which is settlements beginning, monocultural periods, famine emerging, cereals dominating, and this is when we start to see the emergence of nutritional deficiencies.
So for example, I work a lot in Madagascar, in Madagascar, the staple crop is rice.
Now rice is missing a key amino acid, so it's not a complete protein, and it also is missing a lot of micronutrients.
So when you have a population in Madagascar, for example, 50% of kids are malnourished, stunted, because they just, from their basic pattern of Consumption, they're not able to get all their micronutrients.
So you have nutritional deficiencies emerging, and stature decline.
So that's the sign of stunting, which is low growth rate and, low height.
Then we get to pattern three here, which is industrialization and receding famine.
So this is when you have the focus on starchy low variety foods, lower fat, higher fiber, and still, in all three of these cases, really consuming water as the main beverage.
It's labor intensive, so you also have calories that are expended through labor intensive work at home, or out in the industry.
And then when you're having stunting, and micronutrient deficiencies.
Now this pattern here where, for example, you're going then to having an increase in non-communicable diseases.
So this is where we're talking about the pattern, and what you would have read about in the articles you were assigned for today, which is that you see in countries, Brazil, Mexico, Ghana, countries you may not expect.
You have actually increased fat consumption, increased sugar, processed foods, higher calorie beverages, and this shift in technology.
So this is then when obesity is emerging, and then the nutrition-related chronic diseases, such as diabetes, and hypertension.
And then, [LAUGH] then where do we go from there?
And Wendy's gonna talk to you about, where do we go from there in the United States?
And this is really the challenge, is moving then from pattern four to pattern five.
And we know that no country to date has reversed its obesity epidemic.
No country to date has reduced the prevalence of obesity, we haven't really learned very well how to get to get from pattern four to pattern five.
Ideally then, we would have pattern five, which is reduced fat, increased fruit and vegetables, and carbohydrates, increased water, and a reduction on the kind of concentration of caloric beverage intake.
And then replacing sedentarism with purposeful activity.
So this is really the stages of nutrition transition.
And what I'm gonna be talking about today is really just going from pattern three to pattern four.
So you might be asking, what's driving this transition?.
And it really has to do with many factors, and we'll talk more specifically about what they are.
But it really has to do with increasing life expectancy, urbanization, increase household income, which is allowing you to purchase more goods outside of the home, economic growth and globalization.
And then it's unhealthy lifestyle.
And I'll talk in more detail about each one of these issues.
[LAUGH] wonder what that was. >> [LAUGH] >> So as a consequence of these patterns, and of this change.
So this is really a demographic transition, leading to an epidemiologic transition, leading to a nutrition transition.
What you see now is a prevalence of obesity which might surprise you.
So this is a map developed by Barry Popkin at the University of North Carolina.
And you can see this is the patterns of overweight and obesity, globally, from these nationally representative samples.
And you can see here this is now to 31 to 40%, overweight and obese among adults.
And over 51% is the pink.
Take a moment to look at this map.
And I'm shocked every time I see this map, because it's shocking to me that there are countries in Africa, South Africa, for example, that has a high prevalence of overweight and obesity.
Mexico, a country where I've worked, for almost two decades, the prevalence of obesity is almost as high as it is in the United States.
The prevalence of diabetes, in Mexico, higher than the United States.
14% of Mexican adults are diabetic, and 12% in the United States.
So it's really remarkable that the countries, for example, African countries, and South American countries, and Asian countries that have the co-currents of low consumption of foods, and also higher consumption of foods, or just very poor quality of foods, which could lead both to stunting, and to obesity.
You may think, well maybe this is just in adults?
And this is problems of adults?
But you can see from this graph, these are countries in comparison to the US, Mexico, Brazil, Saudi Arabi, Iran, South Africa, Seychelles, Hong Kong, and China.
Mapped from 1971, up to 2012, and showing you the prevalence of childhood overweight and obesity.
Well certainly, we're number one, US, in terms of the prevalence, and Wendy will be talking to much more detail about this.
But you can see that all these countries, look at that sharp line, and that sharp increase, in terms of the increasing prevalence in child obesity.
So we really are seeing this among the adults, and we're seeing it among the kids.
And it may be that there's just a real shift.
If you're interested in reading a book about this, The World is Fat, by Barry Popkin, is really an interesting look at this, and the trends.
I'm gonna be talking a little bit about his book tonight, too.
So here's the mismatch, okay?
Our biology tells us one thing, and our environment provides another.
For example, we have preferences for sweetness.
This has been really important, evolutionarily, that we seek out sweet foods, and then what do we have in our environment?
Well our technology has allowed us to make cheap caloric sweeteners, and food processing much more easily.
So this sweet preference that's biologically driven, is paired with an abundance of sweetness.
So this is a recipe for disaster.
Secondly, we have a thirst and hunger satiety, mechanisms are not linked.
For example, if you have the same amount of calories, what this means is you could have the same amount of calories in a meal, and you put it in a beverage, your body does not experience those calories the same way.
You don't feel as full if you have a beverage that has the same number of calories as if you have in a food.
So this is part of the reason, too, that with all of these high calorie beverages, the beverage revolution, we are then far exceeding the number of calories that we should eat in any day, because our bodies aren't perceiving the satiety cues.
Thirdly, this is, again, another biological issue, which is that we have preference for fatty food.
Again, this drive for sugar, the drive for salt, the drive for fat, these are all things that kept us alive.
And now they're killing us because we desire the fatty foods.
And then we have this edible oil revolution with higher yield seeds, and much cheaper oils.
And so then, fast food, and fatty foods can be much cheaper.
And then we also have the desire to eliminate exertion.
So we are desiring to be still, to be sitting, to be lying, to be sedentary.
We think about all the innovations we've made, so that we don't have to be sedentary, computers, [LAUGH] bicycles- >> [LAUGH] >> Cars, every possible thing that we can do to get around without having to exert too much.
And so then we have all this technology, and all phases of movement and exertion that clashes with our biology.
So really, all of these forces are clashing, and then setting us up for failure at at global level.
Here is the crux of the double burden.
So this is called the double burden because it's the double burden of malnutrition and obesity.
So pick a country of your choosing on this graph.
And you can see here, for example, I will pick Rwanda.
And what you see in the dark line is the prevalence of a mother being overweight, so a mom being obese.
And so that you would have, in Rwanda, over 30% of moms are obese, and over 40% of kids are stunted.
You can even have this in the same household.
This is at a population level.
You can have it in the same household, it's very common that you have an obese parent, and then a stunted child.
And in some work that I did in Mexico, we found that there were children who were 10% of indigenous children.
Or obese and stunted simultaneously.
So, if you think about any time you might come up with a solution for undernutrition, for example, well, let's just feed kids more, 'cause they obviously need the calories.
That's the kind of solution that then may end up promoting obesity and other nutrition-related chronic disease.
So the question is, why is this happening?
Why do you think that there's such an abundance of calories available in low and middle-income countries?
Why is there such a high prevalence of obesity and overweight?
And why is it that these conditions are occurring together?
I'm gonna ask you for one second to turn to somebody next to you and discuss this question.
Then we'll come back in like a minute after you discuss it.
'Cause I wanna hear some ideas that you're gonna shout out.
If you're not sitting right next to somebody you can lean.
There we go [LAUGH].
I see leaning.
It's good, I like this.
Yeah. >> [INAUDIBLE] >> No.
>> [LAUGH] You okay, you comfortable?
>> That's what I am.
Totally comfortable. >> At ease?
>> Calm, cool?
>> Never been calmer.
>> [LAUGH] Anyone who does it without notes in my book is like, I don't even know how you do it. >> I might just call on you. >> I'm sorry.
>> I'm sure you've been talking about it enough but I'm sure [CROSSTALK]. >> Are you guys ready?
You got some ideas?
Anyone, any brave souls to volunteer your ideas?
Please, fast food?
Absolutely. >> Change of diet.
>> Change of diet, absolutely.
Did you have one?
Cheap diets, absolutely.
What else do we have? >> Social trends.
>> Social trends, and what do you mean exactly by that? >> [INAUDIBLE] >> She went to Cambodia a few years ago.
>> [INAUDIBLE] >> Can everyone hear her?
All the restaurants are mom and pop markets. >> Restaurants, and the McDonald's had white tablecloths. >> But the McDonald's had white tablecloths.
Has anyone else been in a McDonald's with white tablecloths or a very fancy McDonald's?
Yeah. A lot of people have that experience.
It's really, yeah, absolutely, it's about what the perception is of fast food.
Other ideas?
Yeah? >> [INAUDIBLE] >> What about it?
>> [INAUDIBLE] >> Mm-hm.
>> [INAUDIBLE] >> Right, so they may know that those are markets that are growing. So maybe they've maxed out on how much soda they can sell in the United States. But they certainly haven't maxed out on the amount of soda they can sell in Ghana.
Do you have a one- >> Sugar is cheap and it lights up the same part [INAUDIBLE]. >> Sugar is cheap and it lights up a very special part of your brain, the happy part.
Yes, absolutely.
Did you have one?
>> [INAUDIBLE] >> [INAUDIBLE] >> So lack of opportunity for [LAUGH], too much sedentary activity.
Lack of opportunity to exercise.
I know her.
Leah. [LAUGH] Yes?
>> Food marketing.
>> What about it?
>> Industries market to children specifically or have really good marketing techniques, and they know their market, and they know [INAUDIBLE] themselves that [INAUDIBLE].
>> So industry choose children to target with their marketing, and they're targeting them directly.
You'll hear Marion Nestle, one of the greatest phrases I've heard her use is pester power of children, because they market to kids who don't have their own wallets, but sure can pester the heck out of you if they want something in the supermarket aisle.
None of you guys did that, I know. >> [LAUGH] >> [INAUDIBLE] >> Right so you could end up, micronutrient deficiencies in spite of having calories.
So you could end up with a high calorie food or beverage that doesn't have any micronutrients.
So somebody would be full, but not have enough micronutrients.
Did you have a comment?
Other ones? >> [INAUDIBLE] >> Yes.
>> [INAUDIBLE] >> Hi.
[LAUGH] >> [INAUDIBLE] >> Empty calories.
And why would you describe that? >> [INAUDIBLE] >> Mm-hm.
>> [INAUDIBLE] >> Right.
So that's exactly it.
So soda's a perfect example of empty calories, 'cause it just has sugar, or high fructose corn syrup.
And it doesn't have any kind of micronutrients in it.
Although beverage companies in this country have gotten clever about that.
They make vitamin water, which has micronutrients added to water, and it doesn't have as many calories.
But those are all really great points, and you guys came up with pretty much everything I'm gonna talk about.
So I will add on to those points that you made to say, first, I'm gonna show you a conceptual framework about obesity in general.
This is gonna be relevant to Wendy's talk to you because it's developed by the CDC.
And it's relevant for both globally and also for the United States.
So, at the individual level, really, the most simple way to think about obesity is really to think about input and expenditure.
So input of calories and expenditure of calories.
Although it gets more complicated than that.
And there's certainly people who devote their careers to talking about types of calories and how they're expended.
This is the simplistic version of it.
And then, when we think about the framework of how do we get to a population being obese, you have this individual point of purchase, point of consumption, and then what is leading to that ability to purchase, or that actual consumption, or the ability to exercise, as you all pointed out, are a whole variety of issues related to work, school, and home.
For example, whether you have time for a leisure activity.
What kind of labor you're doing.
Are doing physical labor?
Are you sitting at home all day?
And if you have infections, what your work site food and activity is.
What your family and home environment is.
What your school and food activity is.
And then you can think more broadly, then, to think about community-level variables.
And you might think, in your own mind, what makes you more likely to be active or less likely to be active at the community level?
It could be, is there public transport or not, are there sidewalks or not.
Is there healthcare available, sanitation, certainly.
So there are a whole range of different factors that are affecting obesity and the prevalence of obesity.
And then, what you have on the global scale, the real difference between what we're talking about in the US, which would be everything to the right, is the globalization of markets, and then economic development, and then media programs and advertising.
Because those are often under-regulated markets and under-regulated.
So, for example, as you would have read in the article talking about Nestle pushing, if you remember, Nestle was pushing for, when Brazil changed their recommendation that babies don't get breastfed all the way.
Babies were getting breastfed to four months.
And they were saying, we wanted to increase the breastfeeding to six months.
Nestle pushed back on that, because that was two months of food that they could have been selling to those babies.
So that's an example where it wasn't as well-regulated, and where those programs and advertising affect it.
So here you see a conceptual framework for obesity, and when we think about solutions, we also think about of all these different levels of types of solutions.
So, here are some factors that I [SOUND] came up with, and this is really, I think, you know, reflecting of the issues that you also raised.
The first is, we have traditional to modern meals.
So exactly this idea, that fast food becomes a luxury food.
McDonald's becomes a safe place that you can, it has white tablecloths, it's a lovely place to go.
There's nice lighting, you maybe feel safer there.
So there are many rational reasons why you may have more modern, that may be a place that you wanna go.
But this is then taking you away from traditional meals.
I would say, there's a picture of a breastfeeding Maybe on the left to also say that there is evidence that breast feeding is protective factor for obesity later in life.
And we also know that Nestle and other infant formula companies continue to promote and advertise for bottle feeding.
I've just been writing a paper with colleagues at the business school with Paul Gurtler and colleagues at the University of San Francisco about the actual effect on infant mortality of the marketing of infant formula.
And it's in the hundreds of thousands of babies who were killed because of the entry of nursing into a country.
So this is the traditional to modern meals, you could think about it all the way down to the level of breast feedings to then bottle feeding.
From traditional to modern snacking, I saw a really interesting study, which looked at the actual number of meals, that people have that differs from the 70s to now.
And if you think about back in the 70s, you would get maybe three meals in a day.
And now, kids might have six or seven meals because they're getting snacks.
You're maybe, Wendy's gonna talk about that too.
But the increase in the number of snacks is really amazing, especially when my kids, I think, I just fed you and then they're asking for another snack.
[LAUGH] I think there's definitely a culture of snacking.
If I pick them up from school and I don't have snacks.
And where's the snack?
Where's the snack?
I'm like, didn't you just have lunch?
How could you?
But there's this culture where everything comes with food and comes with snacking.
And this is also certainly happening in low and middle income countries where there now target marketing.
I saw this in Chile and also you would've read about it in the article, which is that there's a whole market developed for kids, for snacking on the go.
So, it's not just infant formula, now it's also the toddler foods and the graduating foods.
As opposed to just like chopping up what you have on your plate so that a younger child can eat it.
We also have traditional to modern marketing of food, now you're gonna get the expert talking about that next week, with Miriam Missal coming to talk about marketing and marketing tactics.
But this is really where big companies are focusing a lot of their energies in low and middle income markets.
Because they've seen there have been some caps in terms of how much the United States, in terms of how much market is left in the United States?
So they're going outside of the United States to try and find more consumers.
This is a picture from the article you read about Brazil, which is, may have been harder to get products.
But this a picture from the article showing that women are delivering nasty products to people's home.
It's like the Amazon delivery service of junk food is occurring in Brazil, because they are purchasing foods and then bringing them.
And then they are getting some kind of commission for actually getting it all the way to the home.
So there used to be more barriers to getting the junk foods and now there's less barriers.
And we also have shifting cultural norms.
Nobody mentioned this, but I'm gonna read this quote from the Gambia.
Ya Hadi and her brother, Dudu, a recent survey of urban middle aged Gambians revealed that 36% of women were obese, but only 2% of men.
Women have constant access to food when cooking and fat women are considered beautiful.
Under the counter sales of steroids from pharmacies are regularly used to put on body, meaning gain weight, by younger women.
And when I lived in Kingston, Jamaica, this was true too.
That they were using animal steroids to be able to gain more weight.
So there's certainly a cultural element of wanting to gain weight.
And in some qualitative data that I collected in Mexico, there was a sense that having more weight on your body signified that you are healthier.
So it was a sign of prosperity and it's a sign of economic growth and development.
I'll read you this other quote.
Day after day if there's food I'll eat it.
I want to maintain my weight because it doesn't disturb me.
I feel better than thin women, I feel sorry for them.
My babies have always been big and healthy.
So you can see what's happening is that it's almost as if the countries where there's a recent history of having malnutrition, those are the countries where there's more of a desire to make sure to display weight as a sign of wealth.
And like I said in the quality of interviews we did in Mexico, there was definitely a desire to have babies that were heavier.
Because they were less likely to get infections and less likely to suffer in that way.
Here's another quote I really liked from the article about Brazil.
A nutritionist who said, one of the fundamental challenges is persuading parents that their children are sick.
Unlike cancer or other illnesses, this is the disability you can't see.
She's talking about obesity.
Said this nutritionist.
So it may be that women can't see, if for example or perceive obesity or they may not, if they're looking at their children for example, they may not perceive it as a problem.
And I guess the question is about interventions.
If somebody doesn't perceive something as a problem, does that mean we still need to think about public health solutions if there's a perception that's not a problem?
So, the other big trend that's occurring is from low sugar to high sugar.
And this is really like we talked about and like you raised this issue that we are going from a much more traditional diet to a diet that's full of sugar.
You can see here in this graph, that GDP per capita, which is how we measure average consumption within a country, is on the X axis, and then annual soda consumption per capita in liters is on the Y axis.
And you can see the US is up here, with our annual soda consumption of 160 liters.
Who drinks that much soda per year?
Anybody wanna admit it?
No, a lot less?
Nobody here drinks soda, probably.
You guys are all too healthy to drink soda.
And you see all these other countries here, their linear trend line, where as you increase your GDP per capita, you can see the countries increasing their soda consumption.
You can also see here, some trends, these three countries.
Remember when we talked about Nestle was trying to find growing markets for their products.
These are three countries where the consumption, so now this is all of these other processed foods.
So it is just among one of these.
This is carbonated soft drinks, but here we have every kind of processed foods, oils and fats, fruits and vegetables, frozen processed foods.
And this, if you look at the US for example, these lines are pretty flat.
I didn't put the US in here but those lines are pretty flat, they're pretty much flattened out, in terms of how much we're consuming.
But this is where you're really seeing the market growth, is in Asian countries, Malaysia, China, Thailand.
The increase per capita of processed food products and so this really where marketing companies are focussing their efforts and big food companies.
So, here are some examples from a study that was looking at African contexts, of what are the factors?
These are the demographic and epidemiologic factors that relate to having higher prevalence of obesity.
So increasing education is related to having a greater prevalence of obesity in Cameroon.
Same high SES, SES here stands for socioeconomic status.
So this is where having higher SES is associated with more likely to obese or overweight.
Living in a city, being higher age, having more children, feeling unsafe or spending three or more hours watching television per day so that's the sedentary part.
And here is a quote from the article of the New York Times article.
You have more money, you have more food, her son said matter-of-factly.
So this really It seemed to surprise many people when it comes to economic development.
That there's a sense that with economic development, somehow we could promote economic growth while also avoiding the pitfalls of what's happened in our country.
But it appears that we've just made it actually a lot worse.
Because you have rapid economic growth, you have all this unregulated marketing in countries.
And then the influx of cheaper oils and cheaper sugars and that there's foods of low nutritional value.
So, here's another chance for you to talk to your neighbor or whoever you talked to just now, and ask yourself this question or what are the things that you think could be done?
You could reflect on that conceptual framework that I showed you about the different levels.
You could think about policies, you could think about something you read.
I wanna hear your best ideas, I'm gonna be taking notes.
[LAUGH] About what you think can be done specifically about obesity?
Then you're gonna ask them to, right? >> [LAUGH] I'll tailor my questions slightly different.
[LAUGH] >> It seems like we're fine talking.
>> Yeah, totally it's awesome.
>> Is that okay?
I'm just ignoring the YouTube people cuz I'm hoping they just signed up like.
>> No no.
I'm slightly paranoid because we had last year one group come and take over the class who were animal rights activists. >> Really?
>> But they were here on a night when there was someone specifically who talked about, you know.
>> Yeah, yeah.
>> It was like, they did it intentionally.
I don't think they are. >> [LAUGH] >> But it was surprising how many there were. >> That's really interesting.
>> They had people in the audience and yeah. >> Wow.
Sorry about that.
Hm? >> [INAUDIBLE] >> What's that?
>> I'm like, should I?
>> They're mostly talking.
>> It's good, I like it.
>> It's good.
>> I'm so impressed.
So quiet. >> I have some good ideas.
Some good ideas. >> [LAUGH] Yeah, all right, do you have some ideas to share with everyone?
I'm sure you do have great ones.
Who's ready? >> Become media savvy.
>> Become media savvy.
So what do you mean by that? >> I mean that [INAUDIBLE] >> Mm-hm.
>> [INAUDIBLE] or find out more about it, so [INAUDIBLE]. >> Don't just take it out, so that's a suggestion, say, as an individual, to become more media-savvy and don't just assume that the people who are pushing a particular product have your best interests in mind. >> And have campaigns for communiities.
>> And, great, right, so have campaigns for communities to be more aware and understand what where their product is actually being pushed or what the other agenda is.
It's great to be a smart consumer.
That's a great suggestion, yeah? >> [INAUDIBLE] >> Mm-hm.
>> [INAUDIBLE] >> Mm-hm.
So Nestle bringing in economic growth within Brazil.
>> About things like that because of- >> Because Nestle is bringing economic growth and jobs. >> Yeah for the various of one- >> But it's one sided to think about.
This is great the economy is developing the GRP per capital has gone up, but what the are the consequences or the unintended consequences of that kind of economic growth?
Great, other comments or ideas?
Anybody think about it from the policy side of things?
What policies might be, in play yeah?
Nice and loud. >> To change subsidies.
>> Okay.
>> Like inside one [INAUDIBLE] >> Right, so think about subsidies and highly processed foods.
And then to think about how we could not basically be subsidizing these production of unhealthy foods in other countries, too.
Great suggestion.
Yeah. >> [INAUDIBLE] >> Mm-hm.
>> [INAUDIBLE] >> Soda tax?
>> [INAUDIBLE] >> Great, so the soda tax is, and I'll talk a little bit more in more detail about the soda tax.
But basically thinking about pushing that cost onto the consumer so that they then would modify their own preferences and their own purchases.
Great suggestion.
Other ideas?
Yes. >> [INAUDIBLE] >> So, validating the traditional diet.
So even pattern for one or two, those early patterns before the nutrition transition.
And say, let's go back to some of those diets and some of those earlier recipes and bring back those traditions of a healthier living.
Absolutely yeah.
>> [INAUDIBLE] >> Interesting.
integrating restaurants with learning centers and then also bringing that some of that knowledge from the rural areas to the urban areas.
Great suggestion, yeah? >> [INAUDIBLE] relationship between [INAUDIBLE] well beyond [INAUDIBLE] years.
[INAUDIBLE] scarce [INAUDIBLE] minimum [INAUDIBLE] >> Yes, absolutely.
So you're raising the point that what has been the association between socioeconomic and wealth and obesity over the years.
And I would say, you're absolutely right by traditionally having great wealth is associate with greater obesity.
But the interesting thing tha's occurred over a past several decades is that countries that have gone then to pattern five.
This one where you have health, where you've gone through the nutrition transition and then you have healthier populations.
Those healthy populations are concentrated among the poor or among the rich?
They're, right, so the transition is that then wealth allows you to be more active, it allows you to buy healthier food and it allows you to eat lower calories or to go on a diet if you choose or train for a marathon if you choose.
It allows you to purchase those benefits, so it's a great point which is historically wealth has been associated with obesity.
But what has happened is a shift so that now the richer countries, you have actually obesity concentrated in the less wealthy.
So that's the transition that has occurred.
>> [INAUDIBLE] >> Yes, but so, in the traditionaly poor countries, yes.
So then, the question is, are you gonna give up economic development because you are worried about obesity and hypertension?
No country has said yes, that they wanna give up any economic development, because that is then what goes part and parcel, so far we have not seen any counter examples to that occuring.
Other comments?
Yeah? >> What about [INAUDIBLE] policies, [INAUDIBLE]? >> Yeah, right.
So I'm glad you brought up another policy solution, which is really to think about marketing, and marketing to children and controlling that marketing.
So that's another kind of policy level solution.
And if you think about it across the board, all of those levels of analysis that we saw, at the individual level, at the Household level, at the community level, in workplaces.
All of those places, the policy level, are places where interventions can occur and programs can occur.
And I'll go through a few of them, and then we'll talk about two in particular.
So, The responses, in terms of a theory of change of how to think about obesity in non-communicable chronic diseases in a global context.
There are a fewer general bigger categories of things you can do.
So one is you can have policy actions that provide an enabling environment for healthy preference learning.
So this is saying, this is the first one up here which is basically saying, let's talk about making sure kids learn good food preferences, let's make an environment where it's easy to make healthy choices.
Let's promote, this is the idea of putting things in easy to reach, making sure that foods that are healthy are affordable and accessible to the whole population.
The second kind of big category of intervention is policy actions that overcome barriers to the expression of healthy preferences.
So this may be something where you say, I have a preference for something healthy but I can't get to the store or I can't find that.
And here's this Nestle person coming to my house, selling me some junk food.
And I think, well you know what, it's here, I'm hungry, I'm just gonna eat this.
So that's the second big category.
And then this third is here, policy actions that encourage people to reassess existing unhealthy preferences at a point of purchase.
So this is again, trying to, this is where that example came in where we're looking at marketing and a purchase to marketing.
So this is a very simplistic way of looking at it, but it does provide you kind of buckets for how to think about food policy actions, and this fourth category of food systems response.
So the real question is, what are the most compelling incentives or disincentives for government to develop any kind of agenda for the management and prevention of chronic diseases?
Is it economic?
Is it political?
Is it organizational?
And then how can this agenda exist with interventions to also address malnutrition?
So is it possible?
For example, in a country like Mexico, where you have such a high prevalence of obesity and such a high prevalence of diabetes.
And you still have regions in Chiapas where 20, 25, 30% of kids are stunted, and many, many percentage of kids are anemic, and pregnant women are anemic.
How do you think about a policy that addresses all of those, what seem like conflicting nutritional needs?
So again, no country has really solved this.
But I think where the answer is is somewhere in increasing the quality of food.
Because increasing the quality of food that is available can address both of those problems of under nutrition and also of obesity and overweight.
Increasing the quality of micronutrient availability in foods, like fruits and vegetables, can allow you to reduce your dependence on high fructose corn syrup and other unhealthier foods.
And also it could also improve micronutrient availability for the kids who are malnourished.
But this is really the crux of the question.
I'm gonna show you this framework.
I'm not going to go through each of these.
But for anybody who's interested in this topic, the nourishing framework is a really great overview of thinking about healthy diets and the prevention of obesity and diet related non-communicable diseases.
So this really goes through these categories of interventions.
So for example, food environment, interventions, food system interventions, and then behavior change communication.
So let's just say nutrition label standards, offering healthier foods, using economic tools, harnessing the food supply.
You guys came up with many of these options, but I just wanted to show you that there is a kind of,the World Cancer Research Fund has put together this framework to really think about and help think about how to make those kind of choices and options healthier for people right at the point of purchase, and also to think about it from a policy perspective.
So let's think about this question.
Let's say you have a great plan to reduce marketing to children, or to bring back traditional foods, or to any of those ideas that you came up with.
What would be the barriers to action?
You can just shout out answers if you have them at this point. >> Affordability.
>> Affordability, what about it?
>> The example I'm thinking of is [INAUDIBLE].
Eventually it leads to is by 89% of the food sold at the [INAUDIBLE] other [INAUDIBLE] >> So you end up with expensive foods that are, the healthier foods are more expensive is what you're saying? >> Yeah.
>> So then it's cost prohibitive for people who need it. >> Right, and the programmatic scope is narrow cuz it's private land use.
[INAUDIBLE] >> Mm-hm.
So I think that really relates.
That is certainly a great example in the United States.
And it relates to the low and middle income countries because of the same issue having to do with affordability.
And the fact that the foods of minimal nutrition value, the junk foods, are coming in at much better cost, much easier to purchase.
Other ideas?
Other barriers.
Yeah, yeah. >> [INAUDIBLE] >> Behavior change is hard, so true.
Who's ever tried to do something, like not eat sugar or not drink beer or get more exercise?
Anyone?
Yeah, it's hard, right?
It's hard.
Behavior change is hard, and getting people to change.
Even changing your own behavior when you wanna change it is hard.
But then what if somebody else tells you to come and do it and you don't want to?
That's even harder.
Other ideas, barriers? >> Corporate interest. >> What kinda interest? >> Corporate- >> Corporate interest, absolutely.
Right, yeah, yeah, yeah, exactly.
And you'll hear a lot about that next week from Mary and me.
Corporations have to keep increasing, they have to keep growing in order to keep their shareholders happy.
So there's definitely issues of corporate interests.
Other ideas, other barriers?
I'll show you the ones I came up with.
So food industry, you got a lot of these, most of them.
Food industry lobbying, the restaurant industry pushing their own agenda.
A restricted ability or unwillingness of governments to implement policies because they get paid off.
Did you see in that example, was it in Brazil, where the formula companies were then paying off the government and making big donations?
Absence of civil society pressure because there's not enough push back from the population.
Insufficient empirical evidence an assessment of effects of programs and policies, you'll see this when we get to the soda tax question.
And then the consumer demand.
This comes back to the behavior change issue and back to that disconnect between our desires and our biology and what's available.
Which is that consumers keep demanding products even despite of the fact that their hearing that it's unhealthy, that they don't really want to.
What did you say? >> Advertising.
>> In advertising, yes.
Right, well and it's also that the food tastes good, right.
We need food.
So it's not, we often compare the food industry with tobacco and it is similar in some ways and also different because we have an actual biologic need for food and then it depends on what food is then available to you I wanna make sure Wendy has enough time.
So I'm gonna spend the last two slides are just talking about the two different examples of policy intervention.
So Chile's ban on using mascots to advertise to children.
So this was from the article.
So you can see the picture with and without, with and without, with and without.
So here's the question, what do you think of this approach?
Is this innovative or is this food terrorism as some of the People who are against it call it.
Do you think it will have effects, and should they all be banned, or should they be used to sell healthy foods?
What if we put these mascots on carrots?
Does that mean it's okay to use mascots?
It's a question I'm asking you to discuss with your neighbor for 30 seconds, and then we'll get back together and think about this question.
>> [COUGH] >> Honestly.
>> [LAUGH] I know.
What do you guys think?
What do you think of this idea?
First of all, good idea, bad idea?
Food terrorism.
[INAUDIBLE] yeah, opinions, ideas, reflections?
Anyone? >> [INAUDIBLE] >> Less intriguing, less likely to.
>> Less attractive.
>> Right, less attractive.
That's probably their industry wants to keep the cartoons, right?
Yeah, [INAUDIBLE] >> [INAUDIBLE] >> So it's a slippery slope whether you should allow them at all, or whether is this, you would not allow them here, but then you would allow them some other place.
And then how do you draw that line?
Is what you're saying?
Yeah, that's a good point.
Yeah. >> [INAUDIBLE] You need to say, hey, this might be cool if we used market carrots.
But then, I feel like the definition of healthy foods that we could add that to would then be co-opted, and then the corporations would decide that healthy food is in then- >> And who decides what healthy food is then?
I swear, I saw a bag of, this must have been a phase in marketing, where I saw SpongeBob on a bag of carrots.
[LAUGH] My kids were like hey, there's Sponge Bob.
I was like I don't know if I should buy this to support the carrots or not to like be anti-SpongeBob.
I had a big, yeah, vegetable section meltdown there about that.
Because I think it's a natural question then who decides what's healthy and who decides who gets the figures.
Other comments yeah.
Overreach.
So why aren't the healthy cereals using the mascots that could attract kids? >> They could develop their own logo that's attractive and fun for the kids and then they could get all the kids eating more bran and less sugar.
Yes? >> One thing about banning.
If you start to ban mascots on cereal than it's gonna spill over to banning all those.
And then if you hear the problem in agency in the agency, so it's gonna be too messy I think to even be concerned about. >> So this idea of can you use them at all- >> [INAUDIBLE] >> You're saying maybe because it's such a slippery slope we should just restrict it to the sugar cereals, or not do it at all?
Not ban them at all? >> [INAUDIBLE] >> Just let it be.
>> [INAUDIBLE] >> Come up with another idea.
Yeah, that's definitely a point of view which is to say, look, let companies do their thing.
Let's figure out another approach. >> [INAUDIBLE] >> That's gonna be effective.
So, let's talk then about another approach that a country used which was the soda tax in Mexico.
I'd Just briefly for anybody who wants an overview of how this might work, so you had a tax on a sugar, sweet and beverage.
So, retailers don't absorb the tax, the price is increased.
This is, we're assuming, these are the assumptions that it's an ordinary good, and demand increases if the price goes down and decreases if the price goes up.
So then the idea here, these are all the assumptions, the idea here is that the consumption of sugar sweetened beverages is reduced with a tax.
So, and then the idea here is that we would have the prevalence of obesity and overweight reduced.
So I'm gonna ask you the same questions which is, what do you think of this approach?
Is this innovative, or is this a regressive taxation, because this is gonna be an undue burden on the poor?
What kind of effects do you think it would have?
Should we tax all sweetened beverages?
What about high sugar foods?
What about sugary orange juice, or some kind of faux juice that's not real juice but it's high sugar, that's not a soda?
What about high fat foods?
So we run into that slippery slope question again, but it is a different approach, a different policy approach.
You could just shout it out cuz I wanna leave Wendy her full time to talk.
Any thoughts about the soda tax?
Okay you can talk to the person next to you and get your ideas out and then say them to the group. >> [LAUGH] >> [INAUDIBLE] Okay.
All right.
Ideas, thoughts.
If says anything this time I'm calling on you.
Cuz I know you have opinions about soda tax.
You ain't first, all right, there's a point over here.
Soda tax, yes. >> [INAUDIBLE] >> So could harm small vendors who rely on the soda sales, so right, so they may have an undue burden.
So that may not be a good policy idea in terms of their perspective.
Other ideas?
Yeah.
>> [INAUDIBLE] >> Mm-hm, so that if the money from the tax can be used to support diabetes or diabetes research, and that's when you will be more supportive of it.
Other comments about the soda tax? >> [INAUDIBLE] >> So the revenue from the soda tax can be used really to promote public health.
Other comments about the soda tax?
I'll tell you in Mexico, there were some reported effects in terms of reducing the prevalence of diabetes.
But those studies have been challenged because studies using different data set have found different things, And I would say unfortunately also in Mexico, there is an abundance of the beverages that are not juice.
And are not soda, they're like the high sugar waters.
That have like a lot of different flavors.
And then what happens is people were replacing the soda.
Because they didn't buy it any more, with that high sugar so then really all it did was substitute another high sugar beverage with that.
So we do have a long way to go in terms of thinking about sugar.
But it's a start, certainly, and I think that it's definitely encouraging.
So in terms of my very last slide is really just thinking about the core problems with reflecting the effectiveness of the international nutrition system.
Wendy was gonna tell you about all the problems in the United States, but I wanted to just say, at a global level, there are really these weak linkages, this lack of, and many of these apply to the United States, the lack of high level interest, inadequate human resources, unpredictable and inflexible funding, inadequate strategies, and limited sticking power of policies.
All of these things are challenges at the global level.
And I think now I'm gonna turn it over to Wendy, who's gonna tell you about these same issues in the United States.
Here we go!
Here is your- >> [APPLAUSE] >> Thank you!
I'm really here to talk about and really describe for you what it looks like in the United States as we are deep in that pattern four stage that Leah talked about, and trying really hard to get to pattern five.
So I'm gonna give you some details of what it looks like here, what some of the problems look like.
And also what are some of the the things currently in place, what are the things that are promising and also hope to have you thinking about what's next because certainly we've been doing a lot of things.
We're sort of maybe treading water a little bit here, and really there's lots of innovation to come in the future that hopefully are things that all of you will get to do in your careers.
So we've been talking about the international environment and just to think for a minute what is it here that you care about?
I'm sure all of you come at this from a really different angle.
We have people from all different disciplines.
So you all care about something a little bit different.
Anyone want to just say something, why do you care?
What's important to you about food and nutrition in the United States?
Public health, great, what else?
Food insecurity among low income population.
Other things?
Environmental externalities.
I heard someone else.
Land use, great.
Anything else?
Those are the big ones that would come to my mind as well, but there are reasons and all of those things too.
So there are certain things that we care about on an individual level also, that we didn't really talk about, but there's a lot of reasons that collectively this is really important.
And there are land use and economic issues, I come from a public health Discipline so I'm going to focus a little bit on health, not because it's the only thing that matters, or even necessarily the most important thing, but because where, what my lens looks at.
So how many of you know the United States has the most expensive health care system in the world?
So a lot of you do, some of you may not.
This is something that, compared to every to every other nation in the world, as you see here.
We are on the far left, 17.7% of our gross domestic product is spent on healthcare.
Which is far more than any other country, and a lot more even than the next, the Netherlands, if you can't read that.
Text is next to us and they are quite a big drop from us.
And the average of the Organization for Economic Cooperation and Development is there at 9.3.
So we are quite a bit higher.
We spend all this money on healthcare.
We have big political debates.
About healthcare, and yet we aren't the healthiest people, so we spend all this money on healthcare to have sicker people, who live shorter lives than a lot of people in a lot of other places.
This matters a lot because we have to think about how are we spending our collective federal dollars.
So think for a minute about where you think most of our federal money goes.
End of life, definitely our healthcare dollars are very much concentrated in end of life.
When you think about the total federal budget, what do you offers the major elements of the United States budget? >> Social security.
>> Social security, defense.
What else? >> USDA.
>> USDA.
Excellent.
Medicare, yes.
Okay, so heer what our budget looks like.
This is the federal budget this is from 2015.
Okay, so anyone surprised by anything that you see there?
So if you look as you all said social security is about 23% of our federal budget Medicare, Medicaid, affordable care act, chip healthcare programs about 28%.
So when we talk about healthcare being really expensive its also where we are putting a lot of our federal money and we've just had a big tax cut so we're losing revenue rather than gaining but for all the things that you care about that the federal government might spend more on it matters a lot if our healthcare costs keep going up and we also still want to provide the same levels of care that we currently do.
So if we can contain healthcare cost we can spend that money on other places or if we can reduce it by creating a healthier population then we can spend money on some of the things, I bet a lot of things that are small numbers are maybe not even showing on that graph are things that are important to all of you in the room.
USDA or agricultural programs are about 3% of our budget and those safety net programs include some that I'll talk about, which are the federal food programs like SNAP and school lunch.
So those are included in that 13%.
So poor diet is implicated in our healthcare costs.
So what we eat contributes greatly to how our health is.
For example, 86% of healthcare dollars are spent on those chronic diseases, as you saw, which are very prevalent in that stage four, pattern four.
Development, dietary factors are associated with almost half of the cardio-metabolic deaths.
So that's stroke, heart disease, diabetes.
Healthcare cost of obesity alone, there are a variety of ranges of estimates, $147 billion a few years back.
Up to $210 billion but a lot of money spent to treat obesity and as well diabetes.
$174 billion every year to treat diabetes.
So you've probably seen trends of what this looks like in this country.
You saw those graphs of the international picture but what do you notice here?
What do you see on those lines?
Anyone?
So is overweight staying the same or increasing.
So overweight is staying about the same, and what's changing really dramatically? >> [INAUDIBLE] >> It's obesity, so both obesity, those orange bars as well as the extreme obesity.
So people at the very high end of the spectrum are also, that is going up quite a bit.
And among children, that's also increasing dramatically.
Okay, and this is diabetes.
So diabetes went from something that almost no one experienced to this is, now it's up around 7, 8%, and projected, you've probably heard, to be up to 30% of people becoming diabetic.
So we've talked a lot about calories, this is just to show what this looks like in the United States.
So on the left you see 1970, on the right you see 2010, yeah.
So we've increased almost 500 calories from then.
If you've looked at this breaking it down I don't know if you can see those lines by types of foods so those different colored pie for pie day.
Pie bars showing you the types of food.
So are there really big changes in the types of food that we were eating between 1970 and 2010.
So that's not really what's changed so much, I'll show you a little graph that you can see.
But the circles aren't just from a cut paste being funky that the one on the right is bigger, really the total calories has changed.
Okay, so those black bars, on these two slides, this is now looking at 1970 and 2015.
The black bar is our dietary guideline, so we have national advice for what we should be eating as a population.
And if the population were consuming 100% of what's recommended, those bars would be hitting right at that black bar.
But they're not.
So both in 1970 and in 2015 we eat more eggs, meats, protein food than we need according our national dietary advise.
So the only thing that has changed a lot, is I don't know if you can see but that red bar is grains, so we've had a big increase in the grains.
But we haven't made much progress in terms of fruits and vegetables.
So the things that are dietary guidelines really encourage and that we've spent a lot of time and energy trying to encourage people to eat more of.
Haven't budged very much over time.
Our diets are starting to get better.
I would guess if I had been speaking here in probably 1990 and I polled all of the students in the class, I would guess that probably the quality of all of your diets in the room is better than the quality would have been in 1990.
We have started to make some progress in certain population groups, but we are not making progress across the board.
And what this shows is that this is looking at an alternative healthy eating index, which is a measure of sort of general measure of diet quality.
And what it's showing you is in 1999 to 2000, people who were below 130% of the poverty line compared to people who were above 150% of poverty.
So a lower income group compared to a higher income group.
We're pretty close together in 1999 to 2000.
There's been a very slight increase, but really the lower-income group not changing much and the increase being seen in the higher-income group.
Starting to edge up, so starting to make a little bit of progress in dietary quality among a higher income group, but our disparities are increasing.
One of the other things that we see in the US, so Leah talked about stunting and malnutrition in other countries.
We don't have so much stunting here in the United States.
We do have persistent food insecurity.
It's not something that we've measured very well going back in time consistently.
So this was starting around 2000.
But right now we're actually a little bit worse than we were when we hit recession, of course food and security gets worse.
But the Blue Bar is people food and secure meaning that they don't know for sure they have anxiety related to whether they will have adequate food and where they might get their next meal.
The orange bar being very low food security, these are people who change what they eat because they don't have enough food.
So this is persistent in our country, despite us being quite a wealthy nation.
And we do know that food insecurity is related to those health care costs, it's related to well being, it's related to overall health.
This is just showing you a zero, black line would be people who are food secure, and this is looking at the various levels of food insecurity and health care costs.
So on the left people with the worst food insecurity are more likely to have health care expenditures and are more like to have more expensive health care expenditures as well.
That's what the one on the right is showing you.
So we talked about this, you already talked to each other and responded about why, sort of on the international stage, why you think diets are poor.
But just think for a minute, what do you think in the United States is causing this?
So probably we've talked a little bit about marketing.
This is one of things that has come up already in class, and just to see, I like this bar, just came out in a report just the other day.
Really illustrating for you that the amount of money that is spent on nutrition promotion and education in the United States is about $1.1 billion compared to the amount of money that's spent food marketing, that shows $13.5 billion a year.
So we don't spend a lot of money on trying to help people understand what they should be eating or could be eating that would be benefiting their health.
And there's a lot of money spent messaging all kinds of things most of which is not actually consistent with the kinds of foods that we might wanna be promoting.
This is a very old slide, but this hasn't changed very much.
So a lot of people might have been thinking what causes this.
And we've talked about things related to the food systems and the food supply, and how our policies are structured.
So this is showing you from 1996 when we were earlier on in those sloping lines, the food availability compared to the dietary recommendations.
So the black bars are the servings, and the gray bars are what's recommended.
So what do you notice?
Where are the big discrepancies there?
This is what's available in the food supply.
Between what's recommended.
Can you read it?
So grains pretty close, vegetables we have more recommendation than is available but just buy a little bit.
But fruit, quite a big difference, right?
So fruit, recommending three servings per person per day and we produce about 1.3.
In 1996, these trends have not been fixed overtime.
But if you really look down here at the added fats, oils, and added sugars as we're talking about how this transition happens, and what is going on in our environments.
Quite a bit more added fats and oils, and added sugars available in our food supply than is recommended that people consume.
So our environments are flooded with these things and we shouldn't be consuming them, but we can that that is what does get consumed.
Another thing that has changed quite a bit that we didn't talk too much about yet, but is sort of how we eat.
So this graph is showing you, in the United States Over time, the top two, the blue and the yellowish orange bar, are essentially eating out.
So you can see that it's changed a lot over time, in terms of looking at dollars.
But we're spending so much more of our money eating away from home than eating at home, and those environments also are changing.
So this is a slide looking at portion sizes.
So what does this look like?
When we're going out to any environment, what looks normal to us now would not have looked normal to people in 1970.
And for those of you who travel to other countries.
How many of you have been somewhere and the food portions look small, and you come back and you're like, my gosh, this stuff here is huge?
[LAUGH] Right, so a lot of people have that experience.
Because what we are used to and what seems normal here is a very large portion size of food, compared to what we used to have here is normal in other places.
Okay, so highly palatable fluids are everywhere.
We've talked about these things.
We do engineer foods.
We have food science that's been, on the one hand, brilliant, in terms of figuring out what really creates pleasure and what makes us wanna eat.
Unfortunately, it's explaining our biology in such a way that is really damaging for us.
I just said that food is everywhere.
And not only do we eat everywhere but how many of you are surprised when you go into a hardware store and there's a big candy display or a clothing store and there's a big candy display?
Do you expect that now?
You expect it.
It doesn't seem so odd or unusual.
But that's actually very new.
You didn't used to go everywhere like Leah was talking about.
Your kids are used to eating snacks all the time.
You didn't used to go everywhere and be able to buy food.
But now we can.
And when you go to Home Depot and there's food available, what kind of food is available? >> Hot dogs.
Gross. >> Candy, hot dogs, sodas.
Right?
We don't usually see fruits and vegetables available in places that aren't typically selling food.
So one of the things I think about, so right now none of you is smoking a cigarette in this classroom.
Right? I think we would all smell it.
And no one would expect anyone to be smoking in this classroom.
But 50 years ago, if you went and did, this room wasn't here.
But if you went to Wheeler Hall and did a lecture, people would be smoking cigarettes while you're talking.
So the norms are really, really powerful.
So what we expect as food now is it's not helpful for us but can change.
And Leah also talked about and you will hear much more about this from Marian Essel, I'm sure but the industry makes a lot of money selling their products.
And they use that money to wield quite a bit of power and it works quite effectively.
This is just a graph looking at 2017 for those of you who are interested in this kind of stuff.
The Center for Responsive Politics website, I recommend, they have data.
You can make your own charts and graphs, it's kind of fun and interesting.
2017, more than $28 million spent lobbying, you can actually see changes in fluctuations over time.
So for example, I'm gonna talk a little bit about school meals and when the Healthy Hunger Free Kids Act which was a change in federal policy related to school meals was being debated, you see a big spike in lobbying dollars spent by food companies.
They were lobbying to maintain the status quo, not to ensure that we put more fruits and vegetables on children's plates.
Yes. >> [INAUDIBLE] >> Sure.
Wait, what did I do?
Okay, there you go.
So the next slide is gonna show you pictures- >> Thank you.
>> Yes, you're welcome, from a book.
How many of you have seen this book, What the World Eats?
A lot of you have.
If you haven't, I recommended it.
It's a coffee table book with pictures of people, what they would eat in a week, from all over the world.
It's really interesting.
But I think one of the things sometimes, and we're talking about it tonight cuz we're talking about the international and domestic, but sometimes I think we forget actually how cultural eating is.
And we kind of know because we know different parts of the world have different cuisine.
We talk about different kinds of restaurants we might go to.
So we know it and yet I think we have to really appreciate how cultural it is, not just what you eat but where you eat and we know from other places what's available really drives what we consume.
So knowing what's available here in the United States, we shouldn't be surprised that it's what people consume.
And it's important that we change the narrative from blaming individual people to really understanding that people are doing what comes naturally to us.
That's how we are programmed as humans.
And we need to re-engineer our environments to change that.
So this is from an Institute of Medicine report from a number of years back.
But they said, it's unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural, and physical environment conspire against such change.
So this is what we're trying to figure out but, as Leo was talking about, this is hard.
How do you do this?
So one thing I think is important for all of us to really appreciate is these issues, they're not simple.
There's not a single cause of the problem, there's not a single solution.
It is complex but complexity doesn't mean we should shy away from it.
And it doesn't mean that it means it's too big for us to solve, it means it's really interesting and there's a lot of really smart people that need to spend a lot of time and try a lot of innovative solutions to solve it.
This is one of my favorite reports, this is A Framework for Assessing Effects of the Food System, it's a National Academy's report for people who are interested in food systems, I also recommend you check this out.
And they're really talking about how do we make sure that we think about the food systems and all of their complexity whenever we're designing new innovations because sometimes, like Leo was talking about, you have unintended consequences.
Right, so it's important to try to think through.
It doesn't mean you are paralyzed and don't act but maybe we can get better at trying to think through how might the ripple effects of something that you do in one part of a food system affect the other parts so that we're smart about what we try and hopefully we start implementing really effective solutions.
And this is also another model.
Just looking here.
This is from the Lancet.
And thinking about what are all the things that governments can do to solve the obesity epidemic and there are lots and lots of different ways.
I love this also because I think there's something for everybody.
There is some way in which probably every single one of you in the room is interested in something that would be a really important part of the solution to these issues.
One of the things that people have talked about is how do we change communities and recognizing that it's not a single solution.
But how do we reach people from all different places, where they are, and change their environments?
So this is saying, schools can be the heart for kids.
This is talking about childhood obesity prevention but schools can really be the heart.
And then we also need to be thinking about marketing and we need to be thinking about what's available in stores and other retail and what's available, what's happening with employers and what's physical activity.
Can we have a couple questions?
Yeah. >> Not a question, a comment, I'm concerned about affordability again because of the increases.
>> Yeah.
>> This alludes to it but it does not directly target [INAUDIBLE]. >> And I thank you for raising that point.
I agree, it's really important.
And I think we've been a little bit in the immaturity stage of figuring out the food access and we've been thinking about just physical access and talking a lot about how do we get the food there and not thinking about how do we make sure that it's affordable.
I actually just did a study looking just at that and looking in California.
We had data from a variety of low income communities throughout the state and we did see.
We were looking at fruit and vegetable prices and sure enough fruits and vegetables are priced higher in low income communities in California compared to like the average in each county.
So it's a big problem and that was whether you were shopping in a grocery store or any other kind of store.
So yes, we definitely have this challenge. >> [INAUDIBLE] >> What's that?
>> [INAUDIBLE] >> Right.
>> [INAUDIBLE] >> Right, yeah, and I think you heard from Michelle Simon.
Did she come and speak to you all? >> Not yet.
>> Not yet, so she will and hopefully she will talk to you about that.
But definitely, how do we incentivize Fruits and vegetables, and how do we do it smart that it's in a way that really helps the growers and helps everybody else in the system.
And make sure that we do produce enough fruits and vegetables, and we also have enough people to eat them without wasting which is another challenge. >> And is culturally relevant. >> And is culturally relevant, absolutely.
We need to make sure that we- >> [INAUDIBLE] >> Yes, absolutely.
I'm gonna talk briefly just about the school meal.
But yeah, we have made some progress on school meals.
I wanted to just show you a couple, again, like this is all new, and people are trying hard to solve these problems.
So we were involved in a study funded by the national institutes of health.
Really looking at communities and trying to understand I showed you that chart of all the different ways you might act in a community, programs and policies and things you can do to try to start to shift the environments for kids, so that they're exposed to more fruits and vegetables more healthy foods, more physical activity and less of the unhealthy things.
And there's lots of innovation happening all over the country, right?
Like local policies, state policies, various programs.
So can we try to quantify this?
Can we try to understand what's happening?
So this is a national study, and just to show you, now you're looking over a ten-year period.
The right being the most recent, cuz it's retrospective.
Why you have a negative x-axis there.
But what you're seeing is, in all these communities that we were looking at, there's over time an increase just in the number of programs and policies being implemented in these communities.
So people are trying to figure out what to do and implementing solutions.
And this is now looking at body mass index over related to the intensity of those programs and policies.
And essentially showing you that the more intensity you have on the programs and policies in the communities, that the BMI is beginning to go down.
So it's just it's fraught with limitations, this kind of information.
But it's also hopeful in that, you know, we don't know exactly what to do and we don't know exactly what's gonna be most effective, but we're trying a lot of things.
People are trying a lot of things.
And it looks as though that work could be effective, and we can continue to innovate and continue to try to scale things that we find to be effective.
So just to talk briefly about, so that's looking at community programs and policies.
We do have a lot of federal programs and policies that affect what's available in communities, and what people have access to.
So this is just a timeline of our programs and policies in the United States.
Starting in 1946 with our National School Lunch Program, this ends in 2010 with the Farm to School grants.
Are the programs and policies equally distributed across time?
No, so they're concentrated, right?
We had quite a bit of activity in the 1960s and into the early 70s, trying to figure out, does anyone know what was going on then?
>> [INAUDIBLE] >> [LAUGH] >> [INAUDIBLE] >> They did, yes.
So early on in the 1930s we did have famine in the United States.
So of all the things that we have challenges with, one of the things that we have seem to do well is prevent famine.
We have not had famine in this country for a number of years.
We have other challenges, but in the 1940s we established a national school lunch program.
And then we started these programs in the 1960s.
We had surplus foods going to waste in the country and we did have hunger.
We had people starving and we had a very effective CBS documentary called Hunger in America that was produced nationally related to some members of congress who were very interested in exploring this issue of hunger in the United States.
And suddenly there was a lot of attention to it.
And so we started having a lot of programs implemented.
Trying to figure out ways to prevent hunger in this country.
And so all of our programs, none of these programs started except as you get farther the fresh fruit and vegetable program and farm to school grant program which are teeny tiny compared to any of these other ones.
Those ones were implemented to try to address this pattern four where we are.
The others were actually trying to address hunger or agricultural economics.
So the major federal food programs, can you see what's that big red part of the pie?
SNAP.
How many of you, so SNAP is the Supplemental Nutrition Assistance Program.
It used to be called food stamps.
How many of you have heard about SNAP in the news recently?
What have you heard? >> [INAUDIBLE].
>> For how many have heard of a harvest box?
So a few of you but not too many of you, great, well we can talk a little bit more about that.
But really important to know are very biggest federal food program, and we have a number of other ones with the national school lunch program being that yellow bar or piece of the pie is our next largest.
And we have a program for women, infants and children.
How many of you have heard of the WIC program?
Okay, many of you but not all of you.
That is a nutrition program directly for women during pregnancy and for children up to age five to really make sure that we protect the nutrition of those populations.
And the SNAP program being our biggest program.
It's critically important and we have a farm bill coming up.
How many of you know that the farm bill is being reauthorized in 2018?
Have you spoken much about the farm bill in this class?
Okay, great.
So SNAP is authorized in the farm bill.
So for those of you who have heard SNAP in the news that's why we're starting a conversation about SNAP now.
And I'm sure you will continue to hear quite a bit about SNAP if you're paying attention to the farm bill.
So we have good data on SNAP about, how it helps families to be able to afford food.
How it helps reduce food insecurity.
But there's a lot of debate about whether or not snap helps people with their nutrition in terms of the kinds of issues that we're not struggling with in the country.
So, anyone wanna guess the biggest expense in the farm bill?
What does most of the money in the farm bill go towards?
>> Subsidies.
>> Subsidies.
Other guesses? >> Fertilizer.
>> Fertilizer.
[LAUGH] So, what do you see here?
So, the farm bill is dramatically in terms of dollars about SNAP.
And the farm bill we couple the SNAP program with agricultural policies does anyone know why we do that?
Any thoughts?
So it started because you used to have most of the rural members of congress representing the farming areas, the agriculture areas and most of the urban members of congress representing areas where SNACK was more utilized.
And the idea was that in order to have people compromise and come up and make a decision together, you needed everyone to have what you might call skin in the game.
Everyone have to feel like their district had something important in this farm bill, because it's such a huge and complicated piece of legislation.
Now it's actually shifted, because we have just as many people in rural areas as in urban areas that benefit from the SNAP program.
But still it's believed that you can't pass this big package of legislation if you work to decouple.
Agricultural policies and the food piece.
Here are some of the news we heard about this harvest box.
We don't have time to get into it, but if anyone has questions, we can talk about it.
The Trump administration has proposed to cut the SNAP program, and in such a way as to structure it with a recommendation to provide commodity food boxes to people. >> Boo!
>> [LAUGH] Anyone wanna guess why we have a National School Lunch Program?
How many of you ate school lunch?
How many of you had a negative impression or still do have a negative impression of school lunch?
A lot of hands.
How many of you had a good experience with school lunch?
Many fewer, but good, some of you, excellent.
So anyone know why do we have a school lunch program?
Why do you think it started?
It was back in the 1940s, yeah? >> To push commodity crops, they're greatly useful to supplement school lunches.
>> Absolutely, so she said to get commodity crops out and get them in school lunches, and that is exactly why it started.
We started doing that because when we had these surplus commodities, and people were hungry, and it was hard to figure out how do we actually distribute the food before it rots, and is a big public relations nightmare.
People found that distributing to schools was the most effective way to utilize those commodities.
So that's really why we started having a school lunch program.
You might hear other pieces, which is we had military recruits who were unfit for service, and we wanted to do something good for kids in schools.
I've read all the hearing testimony from when the school lunch program was getting started, and I will tell you, it's very clear that the agriculture argument is why we have it.
That the other two arguments were helpful to help to get it passed, but we would never have started having a federal school lunch program if it weren't for agriculture.
The other thing I don't want you to leave here today not knowing is how big these programs are, and how many people in our country participate, because it's very important.
These are not programs for a few people.
SNAP serves one in seven people in the United States.
School meals in California is more than half of kids who are eligible for more subsidized meals, all school lunch meals, whether you pay money for them or you don't, are subsidized to some degree, just less if you paid more money in your family is not low income.
But most of our kids are eligible.
We have that WIC program I talked about.
It's more than half of babies in the United States who are eligible.
So these programs targeted towards low income people, we have very large populations of people in this country who are either below the federal poverty line or very close to that.
So this is just looking over time at how much the school lunch program has grown, it started out quite small, they are much bigger now.
And this is in California, 58% of students eligible for a free or reduced price meal in California, and quite a bit of participation.
And unfortunately, we don't do too well culturally with institutional food in the country, so.
Thus, your experience, which unfortunately, weighs more towards the negative perception of our meals than the positive, and probably because for many of you, your meals didn't look like this one on the right, which is a school lunch from Berkeley from about seven or eight years ago.
But the data do show that kids who bring lunch from home, their meals are actually less healthy than what they're provided at school.
Even when the school meals might be things that you might look at and go, I don't wanna eat that.
But still, what people are bringing from home tends to look like what you see here on the left.
And this is a study I did a number of years ago just looking at fruits and vegetables that shows that, while very few students report eating fruits and vegetables at school, the students who actually eat the school lunch eat more than the kids who don't eat the school lunch.
So just to conclude, we have a lot of really important programs and things that we do to try to make the nutrition of the population work.
But we have dietary guidelines, we spend a lot of time and effort developing them.
There is a lot of controversy about them.
And yet we've had them for since the 1980s, and we really haven't done very well bringing the population towards eating more closely aligned with them.
We have food assistance programs, but we still have persistent food insecurity and poor nutrition.
We have lots and lots of unhealthy food in our environments, and lots of cues to eat them.
But there is a lot of innovation happening.
There's a lot of hope.
There's a lot of progress.
But I feel like we've been tinkering at the margins.
We've been making little bits of progress.
We've maybe stalled out.
Things getting a lot worse in this country.
But I'm convinced that many of you in this room are gonna leap us forward.
Because it really feels like that's where we are.
We're at this point where we've been doing a lot of things for about 20 years now?
And we've made some progress, we've learned a lot, but we're ready for that next episode.
So eat, think, vote, stay engaged, and hope you all will be a part of the solution.
Thank you.
>> [APPLAUSE] >> Okay, sure. >> Yeah.
>> [INAUDIBLE] >> Not yet.
>> [INAUDIBLE] >> So everybody could just stay put for a few more minutes, I know we're really butting up against the end of class.
We're gonna skip Q and A today, and just know that you have access to these amazing, brilliant women in various ways.
We also, I think you guys know, record this, and it's available to watch on the YouTube recordings.
There's so much information that came through tonight, it's amazing.
And you can access that on the YouTube video.
And I just want to say thank you so much.
This was really, really, really- >> [APPLAUSE] >> [INAUDIBLE] informative, yeah. >> You as well.
>> [APPLAUSE] >> [COUGH] I think we all appreciate, and I know professor Rosen's wife appreciates the kind of promoting yourself as an agent of change, in the middle of what seems really overwhelming sometimes problematically.
And like, there is some dark evil force at work that we can't seem to crawl out from under.
It's overwhelming, so I really appreciate the positive points that you brought.
And also, everyone, we're really looking forward to seeing Marion Nestle next week.
That's gonna be great and a really special treat to have her fly out from the East Coast and spend some time with us. >> Rohini's getting the clicker ready.
Are you almost ready?
[INAUDIBLE].
I guess we could have done the clicker, but I think it was fine.
I thought it was- >> I can't seem to move it forward.
I just thought, yeah it was fine.
>> It's not moving forward.
>> [INAUDIBLE] >> There it goes.
Okay, thank you.
Do you have the attendance question?
That.
[LAUGH].
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