Towards a new paradigm for public health

Food-Vegetables-01In 1990, physician and health economist Christopher Murray at Harvard University and medical demographer Alan Lopez at the World Health Organisation embarked on the first ever attempt to measure the global burden of disease and developed the now-famous Disability Adjusted Life Year (DALY) metric that made it possible to combine estimates of mortality and morbidity burden around the world. DALY is the sum of years lived with disability [YLD] and years of life lost [YLL].

Since then, there have been estimates in 1999 to 2002 and 2004. But the latest iteration of the project, Global Burden of Disease 2010, has been on a different scale, involving nearly 500 researchers from more than 300 institutions in 50 countries. It is the largest ever systematic effort to describe the global distribution and causes of a wide array of major diseases, injuries, and health risk factors.

Twenty years ago, the project assessed the burden of 107 diseases and injuries and ten selected risk factors for the world and eight major regions over one calendar year. Now, thanks to advances in technology, the availability of data, and the participation of experts around the world, as well as the leadership of a core group of researchers, the scope has increased to 291 diseases and injuries in 21 regions, for 20 age groups, and an estimation of trends from 1990 to 2010. Global Burden of Disease 2010 also includes an assessment of 67 risk factors.

The results, published yesterday in seven articles in The Lancet, are set to shake up health priorities across the world.

In summary, the analysis shows that infectious diseases, maternal and child illness, and malnutrition now cause fewer deaths and less illness than they did twenty years ago. As a result, fewer children are dying every year, but more young and middle-aged adults are dying and suffering from disease and injury, as non-communicable diseases, such as cancer and heart disease, become the dominant causes of death and disability worldwide. Since 1970, men and women worldwide have gained slightly more than ten years of life expectancy overall, but they spend more years living with injury and illness.

There were 52.8 million deaths in 2010 compared with 46.5 million deaths in 1990. Of these, 12.9 million were from ischaemic heart disease and stroke, or one in four deaths worldwide, compared with one in five in 1990. Cancer claimed 8 million lives in 2010 compared with 5.8 million in 1990; trachea, bronchus and lung cancer accounted for 20% of these. Twice as many people died of diabetes in 2010 – 1.3. million – than in 1990, which is higher than deaths from tuberculosis or malaria (1.2 million each). Deaths from HIV/AIDS increased from 0.30 million in 1990 to 1.5 million in 2010, reaching a peak of 1.7 million in 2006. The fraction of global deaths due to injuries (5.1 million deaths) was marginally higher in 2010 (9.6%) compared with two decades earlier (8.8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1.3 million in 2010) and a rise in deaths from falls.

The contributions of risk factors to regional and global burden of diseases and injuries has shifted substantially between 1990 and 2010, from risk factors that mainly cause communicable diseases in children to risk factors that mainly cause non-communicable diseases in adults.

The proportion of overall disease burden attributable to childhood underweight – the leading risk factor worldwide in 1990 – had more than halved by 2010, making childhood underweight the eighth risk worldwide, behind six behavioural and physiological risks, and household air pollution from solid fuels. Other risks for child mortality, such as non-exclusive and discontinued breastfeeding, micronutrient deficiencies, and unimproved water and sanitation, have also fallen. However, child and maternal undernutrition risks collectively still account for almost 7% of disease burden in 2010, with unimproved water and sanitation accounting for almost 1%.

Of the non-communicable disease risks, high blood pressure, high body-mass index, high fasting plasma glucose, alcohol use, and dietary risks have increased in relative importance. This overall shift has arisen from a combination of the ageing population, substantial achievements in lowering mortality of children aged younger than 5 years, and changes in risk factor exposure.

These broad global patterns mask enormous regional variation in risks to health. In sub-Saharan Africa, risks such as childhood underweight, household air pollution from solid fuels, and suboptimal breastfeeding continue to cause a disproportionate amount of health burden, despite decreasing. The shift to risk factors for non-communicable disease was clear in east Asia, North Africa and Middle East, and Latin America.

For people aged 15 to 49 years, the leading risk factor worldwide was alcohol use, followed by tobacco smoking including second-hand smoke, high blood pressure, high body-mass index, diet low in fruits, drug use, and occupational risk factors for injuries. Risk factor rankings in this age group stayed broadly similar between 1990, and 2010, with the exception of iron deficiency, which dropped from the fourth leading risk factor in 1990, to ninth in 2010.

High blood pressure, tobacco smoking including second-hand smoke, alcohol use, and diet low in fruits were all in the top five risk factors for adults aged 50 to 69 years and adults older than 70 years, in both 1990, and 2010, accounting for a large proportion of disease burden in both age groups. Globally, high blood pressure accounted for more than 20% of all health loss in adults aged 70 years and older in 2010, and around 15% in those aged 50 to 69 years. Tobacco smoking including second-hand smoke accounted for more than 10% of global disease burden in each of these age groups in 2010.

Globally, the sum of years lived with disability and years of life lost (DALY), was influenced most by dietary risk factors and physical inactivity – together these were responsible for 10% of the global disease burden in 2010.

Of the individual dietary risk factors, the largest attributable burden in 2010 was associated with diets low in fruits (4.9 million deaths), followed by diets high in sodium (4.0 million deaths), low in nuts and seeds (2.5 million deaths), low in whole grains (1.7 million), low in vegetables (1.8 million deaths), and low in seafood omega-3 fatty acids (1.4 million deaths). Physical inactivity and low physical activity accounted for 3.2 million deaths.

This impressive analysis of global health issues by Christopher Murray and colleagues provides much reason for hope but also challenges the current medical paradigm and global healthcare system.

It shows clearly that the focus of global health authorities in recent decades on reducing infection and malnutrition has paid off – life expectancy has increased almost everywhere. This focus needs to continue to minimise incidence of diseases like tuberculosis, malaria and HIV/AIDs.

It also reveals, however, that the leading causes of death in the modern developed world are conditions which cannot be controlled by vaccinations, antibiotics, improved sanitation or insecticides. The data provide evidence that the risk factors for non-communicable diseases like heart disease, cancer and diabetes, are predominantly related to poor diet and lifestyle.

The large attributable burden for dietary risk factors such as diets low in fruits, vegetables, whole grains, nuts and seeds, and seafood omega-3 fatty acids might come as a surprise to some. The large burden is caused by both high exposure, e.g., low intake of fruits and vegetables in many regions – and large effect sizes.

Given the crucial role of dietary and lifestyle factors in determining long-term health, the answer to alleviating the suffering created by these chronic non-communicable diseases does not lie in the current medical model, with its preoccupation with drugs and surgery. Our doctors are trained to relieve symptoms not to address the underlying causes of chronic disease. Powerful commercial interests in the food, pharmaceutical and health sectors drown out the voices of those who can see that the solution is really very simple.

Widespread consumption of plant-based diets, rich in vegetables, fruit, whole grains, beans, nuts and seeds, together with not smoking and more physical activity, would transform people’s lives and radically reduce healthcare costs. It is not rocket science.

Dr Murray, I salute you and your colleagues for a first rate piece of work. May the truths you have exposed become part of mainstream understanding as quickly as possible and lead to a sea change in our approach to health and well-being.

If you have enjoyed this post please leave your comments below.

If you would like to keep in touch, please click here to sign up for my free e-newsletter and browse my website.

You can also join me on FacebookTwitterPinterest and LinkedIn, where I post interesting information which is not included in this blog.

References

Murray et al (2012). Global Burden of Disease 2010. The Lancet, 13 December 2012.

Advertisements

Healthy Food Healthy Business

Eating out is no longer an occasional luxury.  Consumers in the UK spent a staggering £81 billion on catering services in 2008 (1) and sales on food eaten out have increased by 23 percent since 2003 (2).  Market surveys estimate that between 7.5 and 8.5 billion meals were eaten out in the UK in 2009 (3).  DEFRA statistics suggest that one in every six meals in the UK is eaten out and the catering industry provides at least three meals per week for the average person in Britain (1).  Approximately 20 to 30 percent of each household’s food budget is spent on food and drink consumed outside the home (1). 

So what are the most important factors driving consumer food choices in the eating out market?

Recent surveys by the Food Standards Agency (4) and leading market research organizations (3), as well as sales data from supermarkets (5), indicate that health consciousness has moved right to the top of the consumer agenda. There is growing evidence that consumers are beginning to give health similar priority to price and value for money when deciding what to eat. 

Worldwide, more than 60 percent of deaths are caused by chronic diseases (6), thus almost everyone knows someone who has suffered from cancer, heart disease, stroke and diabetes.  Public awareness of the key role played by diet in the development of many of these diseases is increasing.  People are therefore concerned about the amount of calories, salt, saturated fat and sugar they are consuming.  As eating out becomes more common, the nutritional quality of the eating out diet is starting to receive scrutiny.

Latest figures show that 11 percent of total energy intake comes from eating out (1).  This number would be substantially higher if alcohol consumption were included.  The eating out diet has more fat and less carbohydrate than the household diet. 

Several consumer surveys conducted in the UK and the USA between 2006 and 2009 point to a growing demand for healthier menu items and a frustration at this need not being met (3) (7) (8) (9).  In one UK survey conducted by Consumer Focus (10), 94 percent of respondents indicated a desire for increased availability of healthier food when eating out.  At the same time, Datamonitor reported that 35 percent of European consumers cannot find healthier menu items when dining out (8).  On top of this, consumers are beginning to request more information about the provenance of their food and its nutritional content (11). 

Supermarkets have already reacted to this trend and implemented front of pack ‘traffic light labelling’ to provide consumers with information on the content of major nutrients and on whether the item is relatively healthy (green) or unhealthy (amber or red).  In 2009, Sainsbury’s reported a dramatic shift in purchasing patterns as a consequence of introducing such labels.  Sales of healthier items increased by 40 to 97 percent, whilst those of less healthy items decreased by 30 to 40 percent (5).

The National Restaurant Association reported that 60 percent of US consumers are aware of calorie information when making menu choices and 25 percent use this information to influence their choices (12).  A study published by Stanford University in January 2010 looked at the impact of mandatory calorie labelling in Starbucks in New York, Boston and Philadelphia.  They found that calorie posting led to a 6 percent reduction in calories per transaction.  This was entirely related to food choices and did not affect beverage consumption.  Interestingly, in Starbucks outlets within 50m of a competitor, the calorie posting led to an increase in Starbucks’ revenue (13).

In the UK, the FSA started working with 18 large catering businesses in 2009 to provide voluntary labelling of calorie content of menu items; the outcome of this is still being evaluated.

So the evidence suggests that today’s eating out consumers are cost-conscious, health-conscious and ethically-conscious.  The successful catering business will capitalise on these trends and create value by delivering what the consumer wants.

The good news is that making small and simple changes to menus to reduce content of calories, saturated fat, salt and sugar can enhance both health and profit margins.  Training courses are available to provide information and practical suggestions about how this can be achieved (14).

For example, there is plenty of scope to reduce portion size and reduce costs and food wastage.  The latest National Diet and Nutrition Survey published in February 2010 shows that average intake of protein is almost double that of the guideline intake (15).  Protein content of dishes can thus be reduced, thereby reducing cost.  Likewise, a number of businesses have reported increased margins as a result of reducing fat content of their menu items.

As life expectancy of the burgeoning world population continues to rise along with the incidence of overweight and obesity, the number of people with chronic diseases will increase.  There is also an increase in the number of the “worried well”.  Health consciousness is likely to intensify and caterers who provide healthier menu choices will position themselves to generate healthier businesses.

For further information and practical suggestions for providing healthier menu items, please come to a Healthier Catering Training Course in the UK.  Suitable for caterers and for professionals involved in encouraging healthy eating in the population.

Works Cited

1. DEFRA. Food Statistics Pocketbook. 2009.

2. Mintel. Eating Out Review. 2009.

3. Allegra Strategies. Review. 2009.

4. Food Standards Agency. Quarterly Public Attitudes Tracker. December 2009.

5. Sainsbury’s. Effect of food labelling on food purchasing choices. 2009.

6. World Health Organisation. World Health Report. 2002.

7. Nestle Professional. 2010.

8. Datamonitor. Workplace consumption: targeting a captive audience. 2005.

9. Aramark (NYSE, RMK) Dining Styles. Research presented to clinical researchers and health professionals at the 2006 NAASO Obesity Summit in Boston October 22-24. 2006.

10. Consumer Focus. s.l. : http://www.consumerfocus.org, 2006.

11. Food Standards Agency. June 2008.

12. National Restaurant Association. 2008.

13. Bollinger, B., Leslie, P. and Sorenson, A. Calorie posting in chain restaurants. s.l. : Stanford University, http://www.gsb.stanford.edu/news/StarbucksCaloriePostingStudy.pdf, January 2010.

14. Philpott, J.K. Healthier Catering Training Courses. s.l. : http://www.cookingforhealth-uk.com/healthier-catering.php.

15. Food Standards Agency and Department of Health. National Diet and Nutrition Survey. Headline results from Year 1 of the Rolling Programme 2008-2009. s.l. : FSA and DoH, February 2010.