The challenge of global cancer where do we go next?

Philip James
LSHTM and Chair of IOTF and the Presidential Council of the Global Prevention Alliance

IUNS

IDF

IOTF

IPA

WHF

The big issues?

Analytical: hopeless measures of diet: a fresh look at biomarkers? Genotyping - selective benefits if dealing with specific processes e.g. alcohol dehydrogenases, cytochrome transferases metabolising a single potential carcinogen rather than complex systems like obesity which results from numerous interacting mechanisms Biological markers of cumulative and specific DNA change: we still need to move into analogous stage of cardiovascular disease with LDL and HDL cholesterol, inflammatory and hormonal markers with intermediate indices of arterial damage.

Nutritionally related risk factors contributing to global cardiovascular disease Modifiable risk factors for myocardial infarction: PAR%
ApoB/ApoA1 ratio( top vs lowest quintile): Smoking (current & former vs never): Psychosocial factors: Abdominal obesity(top vs bottom tertile): Hypertensive history: No daily fruit and vegetable intake: Regular physical activity: Diabetes: Regular alcohol intake: Total impact of all 9 factors:
Yusuf et al. INTERHEART study Lancet Sept.11th 2004,364:937-952.

49.2 35.7 32.5 20.1 17.9 13.7 12.2 9.9 6.7 men 90%

women

94%

The importance of diet in amplifying smoking's cardiovascular effects

Northern Europe Southern Europe
Never smoked Stopped smoking <10 cigarettes/day 10-19 cigarettes/day >20 cigarettes/day

600
499

578

600 500 400

500 400
300 309

300 200
132

300
227

200
125 101

178 87

100 0

100 0
CHD death rates per 100,000

From: Keys A. (Ed). Seven countries. A multivariate analysis of death and coronary heart disease. Cambridge, MA, US: Harvard University Press, 1980.

10-year coronary mortality in men

R = 0.84
600

400

200

S. Italian Corfu S. Italian

Japan

0 0

Crete

Yugoslavia

5 10 15 20 % Dietary energy from saturated fatty acids

25

The Keys concept of metabolic epidemiology plus volunteer feeding studies in cardiovascular disease - applicable to cancer studies?
Increasing risk of heart disease

Blood cholesterol Levels

Low

High

Saturated fat intakes

2210
Portugal

Deaths from stroke in different European countries, plotted against urinary salt excretion, derived from the INTERSALT data

1810

r=0.832 p<0.001

1480
Malta Finland Spain Italy

1210
N.Ireland

990
Belgium Denmark England & Wales Germany

810

(per 100,000 per yea

670 550

Iceland

Holland

7.5

8.0

8.5

9.0

9.5

10.0

10.5

Urinary salt excretion (g/day)

What does the Second Report really say? The man in the street's questions What are my chances of getting cancer in a) my life-time b) over the next 5-10 years? Can you give me a chart so I can work out how much benefit I'll get from what you suggest which are my best buys? If I like processed meat exactly how much more risk am I eating it every day vs. once/wk? How much lower risk will I have if I become physically active, eat fibre rich foods or drop my alcohol intake? What does a bigger "relative risk" per unit alcohol or vegetables mean when I don't know my current risk?

Women
Non-smoker
180 6 160 4 140 2 120 2 180 3 160 2 140 1 120 1 180 2 160 1 140 1 120 0 180 1 160 1 140 0 120 0 180 0 160 0 140 0 120 0 6 7 4 5 3 3 2 2 4 4 2 3 2 2 1 1 2 2 1 2 1 1 1 1 1 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 8 10 6 7 4 5 3 3 5 6 3 4 2 3 2 2 3 3 2 2 1 1 1 1 1 2 1 1 1 1 0 0 0 0 0 0 0 0 0 0 8 5 4 7 5 3 2 4 3 2 1 2 1 1 1 0 0 0 0

Men
Smoker

Age

Non-smoker
12 14 17 20 23 8 10 12 14 16

Smoker
24 27 31 36 42 17 19 23 26 31 11 13 16 19 23 8 9 11 13 16 17 19 22 26 31 11 13 16 19 22 8 9 11 13 16 5 6 8 9 11

12 13 15 17 20 9 10 12 14 6 7 4 5 8 10 6 7

65

6 7 4 5

8 10 12 6 7 8

8 9 11 12 5 6 4 4 2 3 4 5 3 3 2 2 1 2 2 3 1 2 1 1 1 1 0 0 0 0 0 0 0 0 7 8 5 6 3 4 6 7 4 5 3 3 2 2 3 4 2 2 1 2 1 1 1 1 0 0 0 0 0 0

8 10 12 14 16 6 7 8 9 11 5 7 4 5 8 6

60

4 5 3 3 5 6 4 4

8 9 11 5 6 4 4 2 3 5 6 3 4 2 3 1 2 1 2 1 1 1 1 0 1 8 5 4 7 5 3 2 2 1 1 1

11 13 15 18 21 7 9 10 13 15 5 6 3 4 7 8 5 5 3 4 2 3 2 2 1 2 1 1 1 1 7 9 11 5 6 7

55

2 3 2 2 3 4 2 3

15% and over 10%14% 69% 45% 3%

2% 1% < 1%

9 11 14 7 8 10 4 5 3 4 3 3 2 2 1 2 1 1 7 5 4 3 2 1

50

2 2 1 1 1 1 1 1

10-year ris k of fatal CVD in areas of high CVD risk

40

0 1 0 0

4 5 6 7 8

4 5 6 7 8

4 5 6 7 8

4 5 6 7 8

HEARTSCORE, Conroy et al. Eur Heart J, 2003

10-year coronary mortality in men - Seven Country Study

R = 0.84
600

400

200

S. Italian Corfu S. Italian

Japan

The striking contrast in global nutritional problems

0 0

Crete

Yugoslavia

10-yr. C

5 10 15 20 % Dietary energy from saturated fatty acids

25

Foci for action in relation to cancer

Alcohol Salt/pres. methods Some meats Fats- esp. trans Sugars

Obesity

Energy Density

Veg/fruits/cereals (whole grain) Physical activity

The energy density of different foods is markedly influenced by their fat content
Burgers S'market pies, pasties
Fat content (g 100 g-1)

Fried chicken

FAST FOODS S'market ready meals (Indian)

Fries (chips) S'market pizzas

SUPERMARKET READY MEALS

S'market ready meals (Italian)

Gambian main meals

GAMBIAN + HEALTHY CHOICE

S'market healthy options

Prentice AM & Jebb SA. Obesity Reviews, 2003, 4: 187-194

Energy density (kJ 100 g-1)

Covert manipulation of energy density: effects on intake

Prentice AM & Jebb SA. Obesity Reviews, 2003, 4: 187-194

Current intakes in relation to ideal international goals

% fat energy
22 55 GR 50 45 40 35 30 25 20

% SFA energy
A GER
20 18

B A NL IT FIN

S GER

16 14 12 10 8 6

FIN

GR NL

A = Austria; B = Belgium; FIN = Finland; GER = Germany; GR = Greece; IRL = Ireland; IT = Italy; NL = Netherlands; SP = Spain; SW = Sweden; UK = United Kingdom

= range of member state recommendations for these nutrients

Institute of European Food Studies (IEFS) Ireland. 2000

Current intakes in relation to ideal international goals

Fibre (g/day)
45 40 35 400 350

Folic acid (g/day)

FIN UK SP

IT IRL NL*

B
300

GER
30

FIN

GR

250 200

NL
25 20 15 10 5

SW

IRL SP
150 100 50 0
* females only

A = Austria; B = Belgium; FIN = Finland; GER = Germany; GR = Greece; IRL = Ireland; IT = Italy; NL = Netherlands; SP = Spain; SW = Sweden; UK = United Kingdom

= range of member state recommendations for these nutrients

Institute of European Food Studies (IEFS) Ireland. 2000

The traditional Mediterranean diet

1500
Fish Fruit Vegetables Cereals Sugars etc. Alcohol

1250

Eggs Meat Fats & oils Milk

1000

750

500

250

S. Italy 1930s Household (CNR) per caput g/d

EURATOM 1960s Household g/d/consumption unit

S. Italy 1960-65 Men (7 country) g/d

Corfu & Crete 1960-65 Men (7 country) g/d

A quarter-pound cheeseburger, large fries and a 16 oz. soda provide:

1,166 calories 51 g fat 95 mg cholesterol 1,450 mg sodium

The keys to success in the food business and in obesity and chronic disease prevention

Price

Availability Marketing

Children's fruit purchases depend on price

Real food prices and early childhood obesity

Mean BMI increases compared with average

0.3 0.2
New Orleans LA

Mobile, AL Houston, TX

0.1 0 -0.1
Chicago, IL

-0.2 -0.3

Pittsburgh, PA Visana, CA

-0.4

Increasing relative cost of fruit and vegetables

Adapted from Sturm R and Datar A. Body mass index in elementary school children, metropolitan area food prices and food outlet density. Public Health, 2005. In Press, October 2005.

The fall in the cost of agricultural commodities 1960-2000

Based on world market prices related to 1990

The progressive fall in sugar prices in association with marked increases in global production stimulated by huge government subsidies

World monthly refined and raw sugar prices

Sources: Coffee, Sugar & Cocoa Exchange, In., & London International Futures Exchange

Government support for producing grain and oilseed crops comes in many forms, from money invested in public universities and government agencies to research such crops, to subsidy payments that make up for low prices, to continued promises of increased export markets for these crops.

US farm subsidies $ billion

25 20 15 10 5 0 1995 1997 1999 2001 2003

EU CAP Expenditures
43.5 bn

Source: Schfer Elinder L., Public Health Aspects of EU CAP, 2003

High energy dense foods (kcal / 100g) cost less ( / 1000 kcal)
1000

oil
800
Energy density (kcal/100g)

butter nuts

600

sugar
400

grains

cheese

Log scale!
desserts fruit fish/shellfish milk vegetables
1 10 100 1000

200

pasta

0 0.01 0.1 Energy cost (Euros/1000kcal)

Darmon, Darmon, Maillot and Drewnowski, JADA, 2005

Increased vegetable oil consumption is a key component of the shift in the stages of the Nutrition Transition in Asia

50
Grams per capita per day

45.4 39

40 30

1965 1985

1975 1995
28.5 22.2

20
11.5

17.8 14.5 11.1 12.5

18.9 15 8.7

10
4.6

3.3

3.4

0 China
Source: Food Balance data, UNFAO

India

Malaysia

Thailand

Enormous cities, enormous food needs

Teheran Los Angeles Mexico City Lagos New York Istanbul Cairo Lahore

Beijing

Seoul Tokyo Osaka Shanghai Hangzhou Manilla

Tianjin Delhi Dhaka

Karachi Calcutta Bombay Hyderabad Jakarta Rio de Janeiro Sao Paulo Buenos Aires

Cities with populations greater than 10 million since:

1950 1975 2000* 2015*
* Projected Source: FAO, 1998b

By 2015, twenty-six cities in the world are expected to have populations of 10 million or more. To feed a city of this size today - for example, Tokyo, Sao Paulo or Mexico City - at least 6,000 tonnes of food must be imported each day.

Leading DALYs in 2000: low mortality developing countries

1.

2. 3. 4. 5. 6. 7. 8. 9. 10.

Alcohol Blood pressure Tobacco Underweight Overweight Cholesterol Indoor smoke from solid fuels Low fruit and vegetable intake Iron deficiency Unsafe water, sanitation & hygiene

6.2% 5.0% 4.0% 3.1% 2.7% 2.1% 1.9% 1.9% 1.8% 1.7%

WHO World Health Report 2002

Selective abdominal obesity in Mexico

(US non-Hispanic whites data standardized to Mexican age structure) Women Waist cm
p > 0.05 p < 0.001 p < 0.001

80
p < 0.005

Men Waist

94 cm
p < 0.005

110 100 90 80 70 60 50 40 30 20 10 0

p > 0.05

p < 0.001

p < 0.001

18-25

25-27

27-29

=>30

18-25

25-27

27-29

=>30 BMI

Women 40-69 years, Height 150-159 cm p by chi-squared

Mexico
NHS 2000, Mexico

US
NHANES III (198894)

Men 40-69 years, Height 160-169 cm p by chi-squared

World average meat consumption per person, 1964-66 to 2030

Consumption (kg/capita/year)

Beef Pig meat Sheep & goat meat

Poultry

1964-66 1997-99

2030

Source: FAO data and projections

Nutritionists advocate a "balanced diet": the emergence of coronary heart disease in the Western world

UN Commission Report: Food & Nutrition Bulletin, 2000.

Changes in CHD Risk Factors in Finland Men & Women aged 30 - 59

56

% smokers

mmHg

Smoking
Men
48

160 150 140

mmol/l
7.2

Blood Pressure

Cholesterol
6.8

Systolic
40

N. Karelia

130
6.4

120
32

110
6

24

S.W. Finland

100 90

Diastolic
5.6

16

Women
8 1972 1976 1980 1984 1988 1992

80 70
5.2

1972 1976 1980 1984 1988 1992

1972 1976 1980 1984 1988 1992

Year

Vartiainen et al., Int. J. Epid. 1994, 23: 495.

Comparing the observed male mortality rates from CHD in N.E. Finland with those predicted from changes in the risk factors.
0

Smoking
-10 -20 -30 -40 -50 -60 -70

Blood pressure Cholesterol

All three risks Observed mortality

1975

1980

1985

1990

Vartiainen et al. 1994.

CHANGING DIETARY PATTERNS IN SCANDINAVIA 1965 - 1990

0.6
1.2

Vegetables (kg/hd/wk)
0.8

Denmark

Fish (kg/hd/wk)
0.4

Denmark

Finland
0.4

Finland
0.2

0
1970 1980 1990

0
1970 1980 1990

Fat (kg/hd/wk)

0.8

Denmark
0.6 0.4

Milk (l/hd/wk)

4 3

Finland

Finland
0.2 0
1970 1980 1990

2 1 0
1970 1980 1990

Denmark

Nat. Public Health Inst., Helsinki, Finland.

Escalating obesity rates in adults

Global Totals % Obese (BMI >30 kg/m2)
35 35

USA
30 30

% Obese (BMI =>30 kg/m2)

25 25

England Finland Sweden (Goteborg) Australia Brazil Norway (Troms) Japan

1980 1980 1985 1985 Year 1990 1990 1995 1995 2000 2000 2005 2005

2002 Obese: 356 million O/wt >25: 1.4 billion 2007 Obese: 523 million O/wt 25: 1.539 billion 2015 Obese: 704 million O/wt >25 : 2.3 billion

20 20
15 15

10 10

Cuba

5 5

0 0 1970 1970

1975 1975

YEAR

IOTF 2007

Projected overweight (incl. obesity) rates for school age children Global total
Prevalence
50 45 40 35 30

Obese 74 mil. O/wt 287 mil. e.g. US S.Arabia e.g. UK

25 20 15 10 5 0 Recent surveys Projected 2006 Projected 2010

e.g. China e.g. India

Americas (1988-2002) Eastern Med (1992-2001) Europe (1992-2003) South East Asia (1997-2002) West Pacific (1993-2000)

Wang and Lobstein, IOTF, 2006.

Annualized change in prevalence of overweight (including obesity) among European adolescents

2.50

Annual increment (% points)

2.00 1.50 1.00 0.50 0.00 -0.50 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Mid-year
girls, adolescents Linear (girls, adolescents) boys, adolescents Linear (boys, adolescents)

Preliminary WHO data, 2007

Impact of weight gain on Diabetes in Asians & Caucasians: also true of Hispanics & the Caribbean
Diabetes 35 30 25
Asian WHO Male Caucasian Male Asian Female Asian limitCaucasian Female

Asian Males O/W Obese

Asian Females Caucasian Males

20 15 10 5 0 16 20 24 28 BMI 32 36 40

Caucasian Females

Sanchez-Castillo et al Mexican Nat. Health Survey data Pub Health Nut. 2005;8:53-60 Huxley R, James WPT et al. Obesity in Asia Collaboration. Ob. Rev. (in press 2007)

Derek Wanless report to UK Prime Minister 2004 & Kings Fund Sept 2007!

Major health problems and costs relate to:

Smoking, Obesity (diet) Physical inactivity

Causes are socio-economic Solutions are socio-economic The Dept of Health copes - cannot solve the problems "However, without .efforts to tackle key determinants of ill health, such as obesity, even higher levels of funding will be needed over the next two decades to deliver the high-quality services envisaged by the 2002 Wanless review."
Wanless et al. Our future Health Secured? Sept 11th 2007

Wednesday 11th Sept:

Wanless D. Reports to the Treasury on Public Health: First Report, 2002; Second Report, 2004

Complementary approaches to obesity & chronic disease prevention

Individual responsibility
e.g. Focus on Health Education - but need understandable food labelling; campaigns selectively help upper socio-economic groups

Changes to the "toxic" environment

Progressively adapt all towns/cities to favour pedestrian/cycling as norm with car restrictions Nutritional standards for food in all government facilities/schools; eliminate trans fats; catering on Finnish scale: fruit + veg. within meal costs Limit/abolish all marketing to children Selectively increase costs of high fat/sugary products; soft drinks
Adapted from Puska P, 2001

Social/employment/medical policies for breast feeding as the norm

Prevalence of obesity in schoolchildren in Singapore weight (kg) for height (m) >120%
%

16 14 12 10 8 6 4 2
1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

New growth charts used since 1994. Source: Ministry of Health, Singapore

Strategies for obesity and chronic disease prevention - applicable to smoking, alcohol and food
Tax high fat sugar and salt products; tax marketing. Subsidise vegetables, fruits Establish standards for imports, local business, food in all government supported outlets. Recruit business UK style nutritional profiling for labels. Ban/restrict targeting children - TV, schools, product placement

Price

Availability Marketing

Annual obesity rate changes and response to feeding programmes - March to Nov. each year
3 to 4 yr. old pre-school children in Chile
25 March November
School feeding makes children obese

New school feeding programme reversing obesity

20

15

School feeding makes children obese!

%
10

0 1992 2000 2004

Uauy R and Kain J. WHO Expert Consultation on childhood obesity. Kobe, Japan, 20-24 June 2005

Societal policies and processes influencing the population prevalence of obesity

INTERNATIONAL FACTORS NATIONAL/ REGIONAL COMMUNITY LOCALITY WORK/SCHOOL/ INDIVIDUAL POPULATION HOME
Leisure Activity/ Facilities

Transport

Public Transport

Globalization of markets

Urbanization

Public Safety Health Care

Labour Infections

Energy Expenditure

%
OBESE AND Food intake : Nutrient density OVERWEIGHT

Health Development Social security Media & Culture

Sanitation

Worksite Food & Activity

Media programs & advertising

Manufactured/ Imported Food

Family & Home

Education School Food & Activity

Food & Nutrition

Agriculture/ Gardens/ Local markets

National perspective
Modified from Ritenbaugh C, Kumanyika S, Morabia A, Jeffery R, Antipatis V. IOTF website 1999: http://www.iotf.org

The Foresight causal map of obesity

Societal Psychology Individual Psychology

Food Production

Intake Physiology

Indiv Phys Activ .

Physical Activity Envir.

Fundamental changes in physical activity: inevitable and optional changes Inevitable:

Rural to urban transition Labour changes; Mechanisation/computerisation of standard work; also home duties e.g. cooking, washing, cleaning Urban building policies: high intensity or US style sprawl? Road and community design Office & supermarket location policies Car policies versus preference for cyclists/pedestrians Policies on free spaces for children's play; lighting for safety e.g. for older people Park/leisure/sports facilities/school PA lessons Ease of transport of perishable foods into towns/cities

Optional:

Options for increasing physical activity to desirable 1.7 PAL

A normal sedentary day
1400 1300 1200 1100 1000

ALTERNATIVE STRATEGIES Daily Walk 60' Jog 20' BMRx11.0 BMRx4.0 Travel (BMR x 2.56) Domestic activity (BMR x 2.82) Once weekly Jog 140' BMRx11.0 Walk 420' BMRx4.0

Work (BMR x 1.60)

Time 900 allocation 800 mins/day

700 600 500 400 300 200 100 0

Active leisure Passive leisure Sleeping, washing etc. (BMR x 1.06)

The day's PAL

1.58

1.72

1.70

2.50

2.30

From Ferro-Luzzi and Martino (1996). Modelling was performed for an average 70 kg male to determine the nature, duration and timing of active leisure required to achieve an overall mean physical activity level of around 1.70. Columns 2 and 3 indicate how this can be achieved by exercising on a daily basis, whilst columns 4 and 5 show what is required if exercise is concentrated into one day per week.

Roads within 500m of a postcode in Sandwell, West Midlands, UK which contain one or more shops where food is reasonably priced and which sell more than 8 kinds of fresh fruit and vegetables

Roads within 500m Roads further than 500m Railways Canals & streams

Shops

Source: Dowler, Blair et al. 2001

Who controls the food chain ?

Global Feed Companies Farmers (large Government subsidies)
Family and other small food companies

Global Food Companies

Local markets, roadside stalls and farm shops

Small food outlets

Supermarkets: the
"food consuming industry"

GENERAL POPULATION
Corinna Hawkes, 2006

Altering sales tax but preserving revenue in Denmark

Reduce vegetable, fruit, wholegrain

tax: 25% 22% Increase tax on butter, cheese, beef, pork, fatty meats: 25% 31% Add sugar tax

NB: income to government unchanged

Smed S & Denver S. Food & Resource Economics Ints. KVL Univ., Denmark, April 2005.

Manipulating sales taxes can benefit the diet of the poor % Intake changes
60
Saturated fat Sugar

40
Fibres

20

0
SOCIAL CLASS

-20

1
The rich

5
the poor

Smed S & Denver S. Food & Resource Economics Ints. KVL Univ., Denmark, April 2005.

Marketing to Children

Manipulating children's behaviour: evidence from the UK government's systematic analysis

Food industry promotions:

Can confuse nutritional knowledge, e.g. whether fruit is in product Change food preferences Change purchasing behaviour Influence choice and consumption by brand Alter balance of food categories eaten
Hastings Report, UK Food Standards Agency, 25th September, 2003.

Proposals for early Government action October 1997

Stop: a) selling school play areas & sports facilities b) eliminating catering facilities Public/private partnerships Capital improvements - link with new integrated community plans Health Promoting Schools Unit: establish in the DfEE. Nutritional standards for school meals needed Change food culture within schools. Set meals in primary schools rather than cash cafeterias Tuck shops and vending machines: improve Food sold close to school: how improve? School Health Services: new role; identified funding. Village College approach to schools Free school meals for families just above income support level?

Consumer purchases with traffic light food labelling of nutrients as proposed by UK's Food Standards Agency. Healthy (green), reasonable (yellow), or unhealthy (red)
Wheel of Health (WoH) JS Ham and Pineapple Pizzeria 356 all 5 GREEN on WoH

42% 55%

'Be Good to Yourself' Chocolate sponge puddings 4 Green, 1 amber

42%
JS Ham & Pineapple Thin & Crispy Pizza 335g 1 red, 2 amber, 2 green

89%
'Taste the Difference' Melting Middle Chocolate puddings 4 red, 1 amber

Sainsbury's Supermarket presentation to The National Heart Forum, UK., 2006.

Illustration of the GDA system

GDA labelling shows percentages of guideline daily amounts per serving

Formulating a nutrition policy for the prevention of obesity and chronic disease

WHO
National Information
Health statistics Dietary & risk fact.surveys Nutritional surveillance Food production Agricultural Food production statistics Market structure Import/export policies Food security measures Public perception Economic evaluation of policy proposals
MINISTRY of HEALTH (HEALTH POLICY GROUP)

FAO, UNICEF, UNESCO, WTO, World Bank etc.

Ministry of health actions

1. Professional training 2. Health promotion national networks (NGO, voluntary Orgs.) national campaign 3. Regional and district food policy 4. Catering establishments 5. Priorities, research and surveillance

INDEPENDENT NATIONAL INSTITUTION

Actions

Ministry of Education Ministry of Information

school & postgraduate education school meals coordinating educational materials

Ministry of re-evaluation of current Agriculture/Environment policies Nongovernmental organizations and consumer representatives Ministry of Trade Ministry of Finance Ministry of Foreign Affairs

Private sector

controls on food industry licensing, cooperative trade arrangements tax, subsidy adjustments policy on import / export trade coordinating regional actions

Potential mechanisms for combating distorted markets

1. Reorganise agricultural policies to bring in line with health needs. 2. Substantial increase in agricultural R&D, with extension work involving farmers (especially women) 3. Focus on special urban storage, refrigeration facilities and transport lines for rural products e.g. fruit, vegetables (WCRF 1st report) 4. Identify principal buyers for supermarkets, importers: need to engage in conjoint quality assurance on nutrient goals - current understanding negligible 5. Introduce national signposting (not ticks) for all food products based on UK Food Standards Agency scheme but criteria based on WHO global goals

World Priorities Copenhagen Consensus 2004

climate change, communicable diseases, conflicts and arms proliferation, education, financial instability, governance and corruption, malnutrition and hunger, migration, sanitation and clean water, subsidies and trade barriers.

The interest and influences of different stakeholders

10
Children Health professionals Advocacy orgs. Parents Teachers Scientists Church Food inspectors Farmers Ministry of Health

Ministry of Education Parliament Treasury Ministry of Trade

Retailers Ministries of Transport & Agriculture Media

President

INTEREST

-5

Advertising industry Food/drink industry

-10

10

INFLUENCE
Lobstein T : Analyses based on The Food Commission's experience and new EU policy work.

Conclusions
Greater societal challenge with cancer &obesity than cardiovascular diseases which can be limited by "readily" manipulated changes in food composition Toxic carcinogenic & obesogenic environment needs major changes. To improve societal body fat levels need big external changes to overcome buffering by appetite control Systematic multilevel changes: need coherent 5-10 yr adaptable plan led by Governments Industry can help with specified regulations & 5 yr projected changes External public health groups/body: drive change, report to Congress/States not White House; publicly transparent Medical leaders should start working for the public Interest

The cover of "The Economist", Dec. 13-19, 2003.