PSYC 123: The Psychology, Biology and Politics of Food

Lecture 8

 - Nutrition Transition and Global Food Issues


Professor Brownell talks about the situation with world hunger and how it is measured. He reviews the world distribution of hunger, from how many people are affected, to the physiological, psychological, and behavioral consequences of starvation. He reviews how geopolitical issues affect the world food systems in different parts of the world, including climate, war, disease, and refugees.

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The Psychology, Biology and Politics of Food

PSYC 123 - Lecture 8 - Nutrition Transition and Global Food Issues

Chapter 1. From Traditional to Modern: World Health in Transition [00:00:00]

Professor Kelly Brownell: The topic today is the nutrition transition and global food issues. When you talk about how food affects people, enters the body, has an impact on health, on economies, and things like that, things get really interesting when you take a global point of view. The global politics affect food as you heard when we talked about hunger. Global economics affects the availability of food in the prices around the world, and at one point food was so local that what happened to the food world in one part of the world didn’t really affect very much what happened elsewhere in the world but those days are gone. Now things like American subsidies to the corn farmers have enormous impact on what’s happening worldwide. We’ll talk more about that in the economics lecture.

Today we’re going to talk about what the picture looks like around the world and how diets have changed in countries outside the U.S. and what are some of the driving factors that have made this happen. Today we’re going to talk about how there are changes in the global disease burden. As I’ve alluded to in earlier classes, the nature of diseases that cultures are exposed to and countries must confront because of the impact of disease on the economy, on healthcare costs, on productivity, on the size of the workforce when you have major diseases killing a lot of people, you see how important these are and the global burden, the global distribution of diseases have changed. We’re going to talk about changes in diet and obesity in particular, and then I’d like to give you four case studies. We’ll talk about China, India, South Africa and Finland, all different from each other in some ways, but all affected by the same world market forces. It’ll be interesting to go through this.

Certainly world health is in transition. The non-communicable diseases, NCD, are now overriding the communicable diseases. In some countries there’s a double burden where both occur in very large numbers. Now as I’ve mentioned before, communicable diseases would be traditional infectious diseases where people get a specific disease from an agent in the environment. The non-communicable diseases are ones that people don’t catch from something in the environment or from some — or from another person but diseases that are caused mainly by lifestyle, which can also be toxic as I’ve described before. The diets are changing around the world, but not only are diets changing, physical activity patterns are changing. This in turn affects diet, it certainly affects body weight. The aging of the population, especially in certain countries of the world is changing the healthcare picture, and globalization is having a massive impact.

As we’ll talk about later in the class, if you take something like food marketing, there was once a time when if a country had the will to do something about food marketing, it could control what was going on within its borders because there wasn’t much marketing leaking in from the outside, or overwhelming what a country might be doing on its own. But those times are different with the internet, satellite television, etc., the ability of a country to even control what’s going on on the airwaves or over the computer is very limited. Some people may say that’s a good thing, say in countries that don’t have much freedom, that the leakage from the internet from the outside actually helps inform people and is a good thing overall. But there may be some negative consequences in terms of food marketing and things like that.

The global picture is changing to be sure. Now some of the changes are pretty obvious and we’ve discussed or alluded to before. The world is changing from local eating to global eating and that change has had profound impacts. As I said before, the relationship people used to have with food was that they were close to where it was grown, they might know the person who grew it; if not they knew the person who bought it from the person who grew it, and then they prepared it and they and their families ate it and there weren’t many steps between the origination of the food and the metabolism of the food, but now many steps lie in between and more and more people in the world are dependent on food from outside their local area.

This is affected by national and international policies to some extent. We’ll give you some examples of that today. The local traditions have yielded to families eating out, eating large amounts of food, and subsisting on an abundance of food when it’s available, usually at low cost and this has pretty — by now pretty predictable consequences.

The markets have changed, where people buy foods has changed a lot around the world, so in many parts of the world you still see the kind of pictures that are on the left, but more and more you’re seeing the pictures on the right.

Now, it’s a very interesting issue about whether having access to what you see on the right is a good thing. We will talk in this class about how in the United States poor people tend not to have access to what you see on the right, nor to what you see on the left. But what they have access to are small markets in inner city neighborhoods that charge high prices for low quality food. That access becomes a problem and so bringing in something like you see on the right becomes an asset.

In the developing world it appears, from what little we know about this so far, the picture may be different. That large markets that have many choices of processed, packaged, and in many cases imported foods tend to undermine local food traditions, get people away from eating what they might have been eating naturally, and give them access to a wide variety of foods that are less desirable than what they were eating before, because they’re more nutrient poor and more calorie dense. There are differences depending on where you live in the world.

The issue of choice is interesting. As I mentioned before in class, very often when people come to the United States — in fact one of our students in the videotape mentioned this before — they’re amazed by the number of choices and by the size of things that they were exposed too, but people come to the U.S. and they see a hundred different salad dressings in a supermarket, 50 different yogurts, cereals that would fill up a whole aisle with dozens and dozens of choices.

When people come and are confronted by this, it’s interesting to see how they respond. Very often people from other countries say, well why do you need that many choices? I mean what’s wrong with five salad dressings and what’s wrong with six yogurts, and what’s wrong with ten cereals? We have so many that we have this flood of choice that Americans believe is a good thing because the word choice gets connected conceptually with freedom and all that sort of thing; that the idea of restricting choice becomes pretty taboo in our country.

In fact, there is some researchers who have studied this issue of choice. Very often people confronted by choices, where they have too many choices, don’t function well psychologically. It becomes more difficult to make good decisions in the face of a vast array of choices, when a small number of choices would have done. So this paradox of choice confronts Americans because we have so many choices, but it’s beginning to happen elsewhere in the world and people around the world are now facing this sort of paradox of choice where at first glance it seems like a good thing, but in fact, may not be, especially when it erodes local customs.

Transportation is changing a lot and this is changing the physical activity picture. Getting around like this has yielded to getting around like this, and the number of people in the world who are now moving by motorized transport; even in countries like China has gone way up. And this has had a major effect on physical inactivity. Here’s an example of this again, so if you look at China on the left you see pictures of everybody on a bicycle for the most part; and on the right vast numbers of people in cars, but even more so on motor scooters. There’s some research done in China showing that when families secure a motor scooter — which is more and more possible because of the increasing wealth in the country — the likelihood of people being overweight in the family goes up. Even people that are not the primary users of the scooter, so these things tend to have these cascading effects that are very interesting.

Now let’s talk about physical activity in our own lives and you can see how this is going into the modern environment. I mean, my guess is that very few of you have ever even been inside an automobile where you have to crank the window with something like this. Mainly everything’s done with an electronic button. There used to be a time when to tune the radio you actually had to turn a knob rather then just press a button. Of course, think of the remote control that saves you many, many, many trips a year from a chair to a television to change the station.

Each of those, in their own right, may not add up to a lot. But if you take the cumulative effect of all those type of things, and those are just examples, you have an enormous amount of energy people used to spend in day to day life that they’re now not. Add to that the fact that many jobs now are not physically demanding because of the use of technologies and computers, and robots and manufacturing, and on and on, and on.

You see that the population physical activity has declined a lot in the United States and elsewhere in the world. In the United States, it used to be the case that you were paid to exercise. It was called your job. Now people pay to exercise in several ways. You join a club, you buy exercise equipment, but you pay an opportunity cost because of the crazed lifestyle everybody lives. If you take time to be physically active it’s time that you could otherwise be doing other things. You could do other leisure things, you could rest, you could spend time with your family, you could get more work done, there are a lot of different things that compete with exercise, so the fact that it used to be crammed into your day to day life by necessity is no longer the case so much, and this is happening around the world. The number of people in countries like China who have a television, who have motorized transport has increased a lot and this is combining with the changing food environment to create great risk.

Chapter 2. Urbanization, Lifestyles and Chronic Disease [00:11:19]

If we look at things that really — the lifestyle factors that drive the non-communicable diseases, the three big ones are smoking, obesity, and physical inactivity; and then diet would fall under the obesity thing. In the developing world you’re basically seeing these changes happen and then we can’t be surprised that diseases fall from this. So these are big problems around the world.

We’re not talking about tobacco in this particular class, but boy if we did would there be a story to tell. Vast numbers of people smoking in the developing world, just like they are eating a bad diet, being physically inactive, and getting the same diseases that have plagued the United States and that’s happening around the world as well.

We’ll also talk about food industry behavior, because a lot of the growth of some of the American food companies, especially the fast food restaurants, are occurring outside the U.S. It’s not as if the U.S. market is completely saturated, because there’s always more space to cram in fast food restaurants, but we’re probably approaching saturation. Each of the companies is having trouble building a lot because they’re competing with all the other fast food restaurants. But that’s not true overseas, so a lot of the growth in some of these companies is outside the U.S. border as exactly happened with the tobacco industry. The tobacco industry got hammered by lawsuits and by government regulations and bad publicity in the United States; they took their business overseas and have made enormous amounts of money imperiling the health of people outside the U.S. borders. The food industry has been accused by some people of doing similar things.

Let’s look at the changing burden of disease across the world. If you look at how disease is spread — the diseases are spread across different parts of the world, and this graph will be a little hard to see because it’s not that big, but you can see it when you pull it up on the web. The red represents high mortality developing countries, low mortality developing countries are the white, and then the medium blue are developed countries.

At the top of the list you see up there the total burden is — that’s yellow in the middle — is blood pressure. Now high blood pressure and we’ll come back to some more — some recent data on this is contributing to lots of different diseases and seems to be the number one factor that one might intervene (second with tobacco following close behind) that you could do something about to lower the number of deaths worldwide. These various things are spread across different countries or different parts of the SES spectrum with countries, socioeconomic class, spectrum across different countries in interesting ways.

If you look at all the things here, the top things, blood pressure, tobacco, cholesterol, underweight, unsafe sex, fruit and vegetable intake, high body mass index, physical inactivity, alcohol, all those things are driven by lifestyle. Now the hunger less so because that’s a — that can be a problem with food access, but the rest of the things are driven by choices people make in their lives and those in turn are affected by government policy and a variety of broad and powerful factors.

So it certainly makes sense if we want to make the world healthier to think about these chronic diseases and about the diseases that are driven by lifestyle, and in the case of our class we’re talking about this with diet.

Here’s a very interesting graphic that depicts this changing global burden of disease. This is a chart that shows the leading causes of death in rural China. Total population 813 million people-very large numbers of people. I’m going to show you this graphic that has little people figures and each figure represents a certain number of deaths. It doesn’t matter so much exactly how many deaths, but you’ll just see the relative number of little people figures show up here.

First we’ll take communicable diseases; again, the sort of things that you thought would kill people in a country like China, only 2.6% of the deaths. Next are injuries which are multiples of the communicable diseases, so 11% of the people who die in China die from injuries, in rural China that is.

But if you look at the non-communicable diseases, the chronic diseases produced by lifestyle, here’s how the chart looks. An absolutely amazing difference. One would have never thought this was possible in a country like China, but it certainly is. This leads down some interesting roads about what we might do in these various countries.

A paper that came out quite recently talked about blood pressure and I would like to loop back to that, and made the case that 80% of high blood pressure is occurring in the developing world. Now of course if you calculate — if you take into account that China and India, they’re very large populations would be included in this number, you can see why you’d get a large percentage occurring outside countries like the U.S. just because the populations are not in balance. But still, this shows where the world health burden is occurring, and what’s driving it.

This particular study used the global burden of diseases study that’s done by the WHO, the World Health Organization in Geneva. What they did was these investigators looked at the number of deaths from stroke and the number of deaths from hypertensive diseases, and compared high income countries with low and middle income countries. Here are the number of deaths from stroke. Quite a difference between those different types of countries. Then the number of deaths from hypertensive disease look like this. Again, orders of magnitude difference.

So these countries do have to worry about these diseases. They’re happening in very large numbers and they are a huge burden to the healthcare systems in these countries and I’ll play you a couple of audiotape clips that get at this. It’s a very interesting issue. Something that — where some kind of action definitely needs to be taken.

So that’s the down side, the upside is that there are opportunities that if these countries see it coming, if they say well let’s look to our developed country brethren and see what they’ve done and what’s happened to them and we don’t want to get that way, what can we do about it? They may have an opportunity to get involved before business interests take over; before the economic drivers of this are just so profound that the countries can’t turn it around — and even then it may be difficult because global factors are occurring that are helping drive this; but they at least have the opportunity.

Thankfully, some of the countries are beginning to think about this. Countries like Thailand and Brazil have a great deal of concern about growing obesity rates, poor diet deteriorating, physical inactivity, and they want to do something about it, so maybe this early attention in some of the countries will create opportunities for doing some good things.

In this context, the term nutrition transition becomes important, and this has been defined by the people who study it as population shifts in diet that contribute to increased risk of obesity and chronic diseases such as diabetes, cancer, cardiovascular disease and hypertension. This transition, if you read the papers by the people who have really developed the term, has several phases, and various countries in the world are in different phases here.

The person who is most well known for using this term and has probably done more work on it than anybody else, is Barry Popkin who’s at The University of North Carolina and a well-known figure in public health. One of the papers that were in your reading, the one that’s referenced down here was — deals with this nutrition transition. He’s been talking about this for many years and he’s collaborated with researchers in China and Brazil, and other countries, to really find out what’s happening in these countries and to identify the factors that are driving the profound dietary change in various parts of the world. Popkin’s quite a good researcher, if you Google him, if you’re interested in exploring this more you’ll pull up his website at The University of North Carolina. His institute or center there has a variety of resources that you can look at on the nutrition transition and related problems.

Chapter 3. The Dual Burden in Countries across the World [00:20:10]

People have talked about the dual burden that the nutrition transition has helped create. The dual burden is when undernutrition and overnutrition exist in the same country, or in a smaller unit of a country like the same city, the same town, or as we mentioned before, even the same family. In some countries, as many as 60% of the households suffer from this dual burden where you have undernutrition and overnutrition going on in the same family, and the most often cited case of this, but it’s not the only one, is where you have an obese mother and an under it shows how, in some ways, sick, the food relationship is around the world when you see this kind of thing happening. When you add together the under nutrition in the world, which is a major problem, and the over nutrition, and then layer on top of that the fact that somebody may not be particularly overnourished or undernourished by they’re just not eating a health array of foods, then a great deal of the world is affected by this. So changing the world’s relationship to food and changing the foods that people have access too and they wish to eat, can make a big difference in the well being of the world.

This slide will show overweight and underweight prevalence in 36 developing countries and break it down by urban women and rural women. When I pull up this graph it’s going to — you’re going to see lots of bars and data and it’ll be hard to decipher all at once, but I’m going to bring your attention to one particular part of it. The urban women will be on the left, the rural women on the right, and this is done country by country.

You can look to see how big of a problem undernutrition is and overnutrition with — is within a given country and then you can look to see whether there are differences between urban and rural.

Given that we’re going to use India as one of the case examples here, I’ve circled the data for India that you see in the red. If you look at the — the bars circled by the red on the left you have undernutrition on the left, that bar and then overnutrition on the right, the darker bar. The numbers aren’t too different. In urban women you have a lot of undernutrition, you also have a lot of overnutrition, but the numbers seem about the same. If you go to the rural women on the right, the differences are really not — they’re really quite striking differences where there are large numbers of people suffering from undernutrition, relatively small numbers suffering from overnutrition.

This has implications for the urbanization of countries like India and the fact that people in many of these developing countries are fleeing from the countryside into the urban areas changes the risk profile that they suffer and changes whether overweight and underweight is the predominant problem. There will be some sense of that in an audio clip I’ll show you.

You can look at the countries in the UK and look at the percentage of children who are overweight in these countries. Each number shows the percentage of people who — the percentage of children who are overweight. It varies a lot from country to country in — as low as, let’s say 12% in some countries and then you get down to Italy and you get 36%. You’ve got some very large differences, but pretty high numbers overall. It was once thought that obesity was a pretty peculiarly American problem but obviously not the case, so this is a pretty dispiriting number.

Another graph breaks it down by type of countries and where they are in the world, so this would be the number of children in this case who are overweight or obese by region. The total height of the bar shows the combination of these two. The Americans by far have the largest number, Europe is catching up, and then you have smaller numbers in other parts of the world. The question is will those other countries in the world ever catch up to the United States? And if they do, what kind of consequences will this have for them? Here are trends showing the prevalence of overweight children from 1987 to 1997 in a variety of countries. In each case, you’re seeing increases; in some cases you’re seeing quite significant increases. Mexico is now the second most obese country in the world after the U.S., so they’re suffering from a lot of these kinds of problems. These trends don’t look very good. Clearly the world is having trouble with its eating and with its diseases that follow from it, and the trends don’t look very good. They don’t look good in the U.S., they don’t look good elsewhere in the world.

We’ve got a big problem on our hands, so it becomes very interesting to ask what do we do about it. If we take obesity as one of the diet related diseases and ask where it’s increasing the most, you get a chart that looks like this. On the left, the left two bars are the males and females in the U.S., and these are data showing the prevalence of obesity and then we’ll block out other parts of it, so you see Morocco entered into the bottom there, we’ll take Brazil so the numbers are starting to get pretty high; China, now these are the — this is the increase in rates of obesity. You have Thailand here and then you have Mexico here. The prevalence is increasing in the U.S. but it’s increasing much more as a percentage of the population in some of the other countries. So there are places in the world that face significant issues with this.

I mentioned we were going to do four case studies, so let’s start that out, we’re going to talk about China, India, South Africa, and Finland. Obviously different parts of the world facing many different circumstances from one another, but in some ways converging on a common theme that is pretty representative of what’s happening around the world. In these cases, significant issues are happening.

Now, one of the students in the class was kind enough just the other day to send me a copy of a photo she took when she was in southern China, showing the KFC lighted on the street at night. KFC is the most — second most widely recognized corporate logo in China now outside of Chinese companies, so it’s a very big presence in that country, 1700 outlets and growing at the moment.

In China, using that as an example, we have pretty important changes occurring. Something that one would have never guess would ever happen now is, and so there are now treatment clinics in Beijing for obese children. The health authorities are concerned about this greatly. The schools are starting to deal with it, so it has become a real problem in the country.

The rate of obesity has doubled in China in ten years. There was a particular study that surveyed 270,000 adults in that country. They found — they estimated that there was 60 million obese people, 200 million overweight in that country, 20 million people with diabetes. Vast numbers of people with a disease that has terrible consequences for the people who suffer from it, especially if the healthcare is inadequate; 160 million have high blood pressure and you saw from the previous chart what that can do, and then vast numbers of people are smoking as well. Now I’m tempted to start talking about the tobacco picture in these countries because it’s so appalling, but that’s a little bit off task.

Let’s talk about obesity and cardiovascular disease in the Asia Pacific Region. There’s strong associations between body mass index and stroke, as well as heart disease, in countries spread across that part of the world. Now the interesting part of this, and I may have mentioned this before, but there are certain ethnic groups that seem to be especially vulnerable to metabolic and disease consequences of increasing weight.

So far, the research suggests that people of Asian descent have the greatest vulnerability to increases in weight. Let’s say you take Caucasian people in the U.S. or other developed countries and they gain a certain amount of weight, let’s call that X, and then at that point the disease risks really kicks in and they start getting increased risk for heart disease, stroke, hypertension, all the other problems. In people of Asian descent that same degree of risk kicks in at a lower number, let’s just say 75% of X, or 65% of X, or 80% of X.

So a much smaller degree of weight gain is producing the same health ramifications that people in other cultures have experienced. That makes intervention or prevention in particular parts of the world, an especially pressing issue, and it’s why the expected rates of diabetes are just astronomical in some parts of the world. That statistic that you see in the bottom bullet point, that the mean age of strokes and heart attacks were ten years younger in China than Australia gives some sense of that particular biological vulnerability.

Chapter 4. Prevention or Treatment? India as a Case Study [00:30:04]

Using India as a case study, we get a very interesting picture. We have to ask ourselves questions like from that chart I showed before, why do hunger and obesity co-exist? Why does it differ from urban to rural areas? What can we learn from this about agriculture and food supply around the world? Now, I showed you this slide before when we were discussing hunger in India, and in this case, the darker colors represent the parts of the country where they have the most significant rates of hunger. Now in the rural areas of this part of India, you’ll have less obesity but in the urban areas, you’ll have more and these problems tend to co-exist.

Now, I’d like to play you a clip from National Public Radio on this because I think it’s very telling and interviews some people in India about this particular issue [video clip].

Well, there’s several interesting things about that clip. First it shows some of the human beings who are affected by this; it talks about the potential healthcare costs of this in a country like India. But it covers certain things and other things it doesn’t, and they’re — embedded in this conversation that we have, is a trap that America fell into, and it’s possible that a country like India will as well and it’s the idea that you can treat these problems away.

Now in the United States, the traditional approach — and we’ll cover this when I come back and do a lecture for you guys on the issue of public health and public health models — the traditional approach in the United States, when there is some kind of a disease that affects health is you treat it and the typical model that we hope works for many diseases would be like an ear infection in a child. There is a disease, it’s easily diagnosed, fairly easily treated, you give people the medicine, the patients are happy, the parents are happy, the doctor feels good about it, everybody wins. That’s the traditional model. That model just does not apply to chronic diseases and it doesn’t apply to obesity or diet related problems in general.

I’ll show you some information later in the class about how we approach this — have approached this issue in the United States, which is to spend billions of dollars on research to treat obesity, very little money in comparison on preventing the problem. That is a trap, it’s like the quicksand is sitting there. Is India going to walk into it?

Now, whether this particular radio clip typifies what the thinking in India is, you can’t make that assumption. In fact, there are some very progressive people in India who are paying a lot of attention to the prevention of the problem, but at least in this radio clip, it was about clinics; it was about treatment; it was about the people with a problem going to some expert that would deliver help once the problem exists, but there was really very little talk in there about the prevention of the problem and that’s a whole different approach. So we have to hope that countries like India will avoid the trap that America fell into and take a different kind of an approach.

Chapter 5. Projected Global Increases in Diabetes and Obesity [00:38:41]

I showed you I believe in the very first class a slide that is the projected increases in diabetes in different countries, and I’d like to show you a few more to help round out that knowledge. If we look in the next 25 years or so about — that are projections on the number of cases of diabetes — and as I said before, nearly all of these cases are driven by poor diet and physical inactivity, and then the obesity they cause — the numbers are really quite staggering. We’re expecting 13 million new cases of diabetes in the U.S. in the next 25 years, that’s a very high number, an alarming number. But in China the numbers are multiples — is twice that and then it’s even more then that in India and so the number of millions of people to be affected is really quite high.

Now of course there is a denominator issue here because the populations are so large in India and China compared to the U.S. that you would expect even a low base rate of the problem to turn into high numbers because of the large populations. But if we look at the percentage increase in diabetes in these countries, you see the picture still remains pretty similar. As the audio clip suggested, the increase expected in India in particular, is very, very alarming.

If we collapse data across all the developed and all the developing countries — and I believe I showed you this one before — you see what the picture is like. Certainly, the health burden is changing around the world, the diet is changing a lot and it’s happening in ways that are having a big impact on disease. So it’s not just an academic matter, it’s a very important matter for even the well being of the healthcare systems in these countries.

I’d like now to talk about — turn our attention to two other case studies that we were going to discuss today and talk about South Africa and Finland. There was a five part series that I urge you to listen too on Public Radio International that was co-produced with the BBC on this. If you go to the website that I — the two web addresses that I give you here it’s for parts I and II and we’re going to listen to those right now but I urge you to listen to all five parts because it’s a very good series.

So PRI International and the BBC decided to do a series of discussions about the global obesity issue. And very interesting about the way they broke this down into different topics, and as you’ll see from these particular clips, there is discussion on the impact on individuals of the problem, but then when the attention turns to Finland there’s more discussion about what might be done to prevent the problems and what kind of interventions might occur. Not necessarily through medical care but through public policy that can have a beneficial impact. Okay, here we go [video clip]. I’ll stop in a few places and just insert a few editorial comments. What’s interesting about this little example in South Africa so far, is the impact of moving to an urban area. The other thing is the interesting concept of how could somebody who’s living in dire poverty in the slums of a city in South Africa have the money to secure that many calories to gain that much weight, as this particular woman has.

As we’ll talk about in our class on economics, poverty drives people towards certain types of food. It used to be the case that poverty drove people towards certain local food selections, which were fine for the most part. It may not have been the best possible food but still it wasn’t going to be overnourishment, but now in many parts of the world poverty leads people to the foods that provide the cheapest calories and those tend to be the most energy dense foods. A very similar picture to what we see in the United States. When you look at the foods that the poor have access too they tend to be the very calorie dense foods [video clip].

Now one interesting part of that discussion right there is that when people move from the rural areas to the urban areas and starting eating a worse diet and start gaining weight there may be way of — might be a way of compensating for that, namely increased physical activity to offset the increased calories. But in fact, people tend to become less physically active in those environments and then you have a double whammy going on if you will. More calories, a worse partitioning of the diet, that is, more things like fat, sugar and salt and less physical activity so less ability to compensate for the dietary insult that’s occurring [video clip].

Let’s look just at that little discussion about the social norms. Embedded in this case study of people in the urban areas of South Africa you have migration from the rural to the urban areas playing a role, poverty plays a role, physical inactivity plays a role, access to certain foods plays a role, and in this little discussion that just occurred, social norms play a role too. This perception that if you’re not overweight it means that you haven’t made it or that you’re infected with a stigmatized disease HIV. All these things are extremely interesting; all play a complicated role in the process [video clip].

Now before we move onto the next segment which deals with a different country altogether, let’s just conclude a little bit about South Africa. You get a very clear picture in this scene about how dire the problem is of obesity and poor diet. Wasn’t it interesting to hear about this special risk posed by under nourishment to later development and how the undernourishment at point of life make create elevated risk in another. Now we can hope that the world health authorities and other countries and South Africa itself will pay attention to this impending crisis and take novel, creative and bold action to deal with it, but again, there are traps that countries could fall into, there are opportunities. It’ll be very interesting to see how this takes place.

Now let’s hear about how a different country has dealt with this issue, in this case Finland. One of the people interviewed in this particular clip is a well-known scientist from Finland named Pekka Puska. He was an incredibly innovative scientist at a time when very few people were caring about community interventions for things like heart disease and he pushed and pushed against great odds to make some changes in Finland. After he did this, he spent time in Geneva at the World Health Organization and then more recently has returned to Finland and he is Minister of Health for the country, but a very interesting player in this whole picture and he has helped change to some extent the way the world looks at intervening with these problems [video clip].

That’s one key about this project in North Karelia that Puska ran: that not only are they focusing on the individual and education, and the sort of typical change people would think about; but he’s talking about intervening in the environment and making changes. This is one of the ways that Puska’s program differed from similar programs in the United States that were not having very impressive results at the time he was. We’ll play this out and you’ll hear more about that [video clip].

73% percent drop in heart attacks for that highly vulnerable group. That’s a really staggering finding [video clip].

Just you wait, we will see what happens. Later in the class we’ll talk about what some of these global solutions will be. You see in a country like North Karelia how — or Finland and that North Karelia area in particular — how vexing a problem this is because even they, with the amount effort that they put in, are having trouble controlling the problem.

Chapter 6. The Erosion of Traditional (and Healthier) Diets [01:04:30]

Two things I’d like to draw your attention to, and then we’ll end with today’s comedy clip. One sign of the change of the diet around the world, is what’s happening in the Mediterranean part of the world and the erosion of that diet which, as we explained before, has considerable health benefits. A number of you — by the way when you guys see things in the press or interesting photos or things that you think might be helpful for the class, please send them to me — and a number of you noted an article that was in The New York Times last week that talked about the erosion of the diet. In this case the story in the Times, which was really quite good, talked about a particular island in Greece called Kasteli and what had happened in that island. They talked about how the traditional food culture that had the components of the Mediterranean diet that we talked about earlier has been eroded and now there is much more imported food, but also Greek versions of the fast food. So in this case you can see pizza, hamburgers and other things on the menu of this place on that particular island.

That was an interesting anecdotal story, The New York Times sent somebody, they went there, they talked to people and they saw what was happening on the ground in that area, but there’s also research on this. There was a report published in July of this year by the Food and Agriculture Organization, which as I mentioned before; it’s in Rome, but it’s part of the United Nations. This compared 15 European — looked at 15 European Union countries, but it took the Mediterranean countries that were in this sample Spain, Greece, and Italy and compared it to the others. If you’d like to see the whole report the website is listed there.

They looked at how things were changing in those particular countries, so if you look at all the EU countries combined on the left and the Mediterranean countries on the right, and then you see what happened between 1963 and 2003 was sodium intake, was salt intake, here is the picture that you get. In 1963 the Mediterranean countries were looking better then the rest of the EU as a group in terms of sodium intake, but in 2003 you can see what’s happened in both sets of countries. The sodium intake has gone way the heck up. That’s a really remarkable increase. The number is much higher then health authorities would recommend. The advantage of the Mediterranean diet is — or the people living in those countries is still apparent, but not nearly what it was before, and so there are real problems there. That represents a 50% increase, 64% increase over here. So the Mediterranean part of the EU is starting to catch up to the others.

If you look at the number of calories per day, per person in these countries you get interesting phenomenon. Let’s look at these three countries Italy, Greece, and Spain, to see what happened over that period of time. Here’s Spain, the number of calories per day, per person — now again that’s happening at the same time physical activity is declining, so we can’t be surprised by problems with disease. The numbers for Italy look like this, and then the numbers for Greece look like this. When you put all this together — I’m going to skip this but it’ll be in — you’ll see it in the slides. There are a number of hypothesized reasons for it. Things that we talked about some today but we’ll talk about later in the class as well. There are now many studies on this particular topic. This one in particular talks about North India and it talks about how men in the rural areas of North India have five times the physical activity, more obesity in the urban areas as the clip on South Africa suggested.

Here’s another example of a study that was done in the Amazon area of Peru. They found, in this case, that the more people adhered to a traditional diet the healthier their diet was. And then this was a paper that was in your readings that talked about the New World Order and how colonization is having an impact and there’s a quote that I don’t need to repeat because it was in the paper, but it shows pretty clearly what’s happening worldwide.

I hope what we’ve painted today is a picture that shows that there’s great reason to be concerned about what’s happening worldwide: opportunities and challenges, but certainly places where we can intervene.

[end of transcript]

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