Obesity: bad trouble is on its way

Dr Margaret Chan
Director-General of the World Health Organization

Lecture delivered to the Women’s International Forum
New York

21 September 2012

Excellencies, distinguished members of the Women’s International Forum, honourable members of the diplomatic corps, ladies and gentlemen,

It is a pleasure to deliver this lecture on noncommunicable diseases, the slow-motion disaster.

I have great respect for the thinking that led to the establishment of this international forum and sustains its purpose. You want to learn. You want to understand the forces that are shaping this world.

You want to be conversant with the challenges that confront the international community, its leaders, the United Nations, and its specialized agencies, including the World Health Organization.

If you are interested in challenges, today’s highly complex landscape of public health has a great deal to offer.

I have worked in public health for more than 35 years. The new challenges and threats that have emerged just since the start of this century represent the most dramatic changes I have ever witnessed.

Our world is in big trouble. The first decade of this century has been marked by one global crisis after another. Multiple troubles have multiple consequences for health.

I am talking about a changing climate, more emergencies and disasters, more hot zones of conflict, soaring health care costs, soaring food prices, ageing populations, rapid urbanization, and the globalization of unhealthy lifestyles.

I am talking about an enduring economic downturn, financial insecurity, shrinking opportunities, especially for youth and the middle classes, poverty that keeps getting deeper, and social inequalities that keep growing wider.

In a sense, this is nothing new. Floods, droughts, famine, war, pestilence, plagues, and economic booms and busts are familiar companions in the up-and-down cycle of human history.

But today’s crises are different. They have some unprecedented dimensions. They are revealing, in ominous ways, what it means to live in a world of radically increased interdependence.

Today’s global crises are highly contagious and profoundly unfair. Even countries that managed their economies well and did not take excessive financial risks have been severely affected by the financial crisis. Likewise, developing countries that contributed least to greenhouse gas emissions will be the first and hardest hit by climate change.

In the view of many, one of the most ominous expressions of the world’s increased interdependence is the recent and relentless rise of chronic noncommunicable diseases. This, too, is the result of forces that are highly contagious and profoundly unfair.

All around the world, health is being shaped by the same powerful forces, like rapid urbanization and the globalization of unhealthy lifestyles. And these are the forces that drive the rise of noncommunicable diseases, all around the world.

The challenges created by these diseases are unprecedented in their scope and complexity. They threaten not only health, but also economies, and call into question the very viability of our health care systems and the schemes in place to provide financial protection.

Throughout human history, the conquering of infectious diseases has accompanied improvements in hygiene and living conditions, and paved the way for further socioeconomic progress.

Today, with the rise of noncommunicable diseases, the tables have been turned. Left unchecked, these diseases, strongly associated with rapid modernization and increasing national prosperity, have the power to cancel out the benefits of economic gains.

Growing evidence shows that economic growth in an interdependent world creates an entry-point for the rise of diseases like heart disease, stroke, diabetes, and cancers, especially cancers linked to tobacco use and unhealthy diets.

These are the diseases that break the bank. In some countries, for example, care for diabetes alone consumes as much as 15% of the national health care budget. The entry point has been opened wide by the pressures of urbanization and dramatic lifestyle changes.

Today, modernization means sedentary city jobs instead of farm labour, TVs and computers that keep kids off the playgrounds, and easy access to alcohol and tobacco products. Above all, it means a shift away from traditional healthy foods to westernized diets and dining styles.

Added urgency comes from the dramatic recent shift in the burden of these diseases. Long considered the close companions of affluent societies, noncommunicable diseases have changed places.

Today, more than 80% of the burden of premature deaths from these diseases occurs in the developing world, with the incidence highest in lower middle-income countries. In these countries, patients develop symptoms earlier, get sicker, and die sooner than their counterparts in wealthier nations.

In most developing countries, health systems were built to manage acute episodes of infectious diseases, in which the patient either survives or dies. Health services are almost totally unprepared to cope with the added demands, on staff, budgets, medical supplies, and hospital beds, that come with diseases requiring long-term, often life-long care.

In addition, these countries are soft targets and easy markets for multinational corporations. Campaigns to warn about the dangers of tobacco, alcohol, and processed foods are rare.

Many countries lack even the most rudimentary regulatory capacity to address irresponsible advertising practices or keep unhealthy products off their markets.

In large parts of the developing world, these diseases are detected late, when patients need extensive and expensive hospital care. On average, at least 50% of this care is covered through out-of-pocket payments, leading to catastrophic medical expenditures for households.

As a result, noncommunicable diseases deliver a two-punch blow to economies. They cause billions of dollars in losses of national income, and they push millions of people below the poverty line, each and every year.

Let me ask: is this what we call progress in our modern world? Let me ask: why is so little being done to stop this from happening?

I can think of several reasons why these diseases are not yet receiving the attention, actually the alarm, the emergency response, that they deserve.

In a sense, this is a slow-motion disaster, as most of these diseases take years to develop. But the unhealthy lifestyles that drive the epidemic are spreading with a stunning speed and sweep.

The impact of NCDs comes in waves. What we are seeing now in much of the developing world is a first wave. This is marked by growing numbers of people with raised blood pressure, raised cholesterol, and the early stages of diabetes.

The growing prevalence of obesity and overweight, seen in every corner of the world, is the warning signal that big trouble is on its way. The second wave, which is yet to come in most parts of the developing world, will be much more horrific.

One statistic tells the story. Of the estimated 346 million people worldwide who suffer from diabetes, more than half are unaware of their disease status. For many of these people, the first contact with the health services will come when they start to go blind, need a limb amputation, experience kidney failure, or have a heart attack.

For cancer, let me illustrate the magnitude of the challenge with two more statistics. Some 30 developing countries, including 15 in Africa, do not possess even a single radiation therapy machine. In some African countries, only 20% of patients survive cancers, such as cervical cancer, that are highly curable elsewhere in the world.

Ladies and gentlemen,

Chronic noncommunicable diseases are by no means neglected diseases. As their initial burden was concentrated in affluent societies with strong R&D capacities, effective treatments are available and constantly being improved, though admittedly at constantly increasing costs.

In wealthy countries, deaths from heart disease and stroke have declined significantly, cancer patients are being cured or surviving longer, and people with diabetes benefit from better monitoring and treatments.

But this apparent success creates a distorted picture. It creates the impression of a manageable situation and conceals what is, in reality, an impending disaster. When drugs are available to reduce blood pressure, lower cholesterol, and improve glucose metabolism, the situation looks somehow under control.

This appearance is misleading. As I mentioned, the high population-wide prevalence of obesity is the tell-tale signal that something terrible has gone wrong in the social environment in which people make their personal choices. It tells us clearly that the root causes of these diseases are not being addressed. For disease like these, and conditions like obesity, that are widespread throughout entire populations, prevention depends absolutely on population-wide measures.

The failure to promote population-wide preventive measures is evident in just a few statistics. Worldwide obesity rates have almost doubled since 1980. The epidemic of diabetes, which is closely associated with obesity and urbanization, has skyrocketed in rich and poor countries alike. This is a world in which more than 40 million pre-school children are obese or overweight.

Comforting assumptions that noncommunicable diseases are somehow being managed carry three serious dangers.

First, they fail to recognize that many interventions used to manage these diseases in wealthy countries are beyond the financial reach of countries with limited resources. Even extremely low-cost medicines become unaffordable when multiplied by the huge number of people in need of treatment.

Second, they fail to consider the spiralling costs of chronic care, everywhere. Treatments and other interventions are constantly improving, but these improvements nearly always come at a much higher cost.

This trend helps explain why national health expenditures in many well-off countries are outpacing GNP growth. A study published last year concluded that the costs of treating cancer are becoming unsustainable, even for the wealthiest countries in the world.

Finally, assumptions that these diseases can be managed blunt the signals of an urgent need for sweeping policy changes aimed at prevention.

From some of the statistics I have just cited, I believe we can all conclude that prevention is by far the better option.

But this, too, is hard to do. The root causes of these diseases, the lifestyle factors, the food available in stores, restaurants, schools, and vending machines, lie outside the direct control of the health sector. Population-wide prevention depends on health-promoting policies in other sectors of government, many of which do not have health as part of their mandate.

The health and medical professions can plead for lifestyle changes and tough tobacco regulations, treat patients, and issue the medical bills, but they cannot reengineer social environments to make healthy behaviours and choices the easy choices.

Some policy decisions are not, on the surface, terribly challenging. For example, full implementation of the WHO Framework Convention on Tobacco Control would deal the greatest single preventive blow to all of these diseases.

But as very recent experiences in countries like Uruguay, Australia, the USA, Norway, and Turkey have shown, a country’s sovereign right to introduce legislation that protects the health of its citizens can expect to be hit with lawsuits from an extremely wealthy, rich, and ruthless industry that can hire the best lawyers and PR firms that money can buy.

As another example, salt in processed foods is a major reason why daily salt intake in most countries exceeds the WHO-recommended level. Salt reduction is one of the most cost-effective, feasible, and affordable of all public health interventions.

But can we count on the food industry to voluntarily reformulate its products so that they contain less salt? Once again, we are at the mercy of an industry which health officials have no power to control.

Ladies and gentlemen,

Yale University’s Rudd Center for Food Policy and Obesity has produced an educational slideshow that helps people understand how the world population got to be so fat. It traces a series of events in the evolution, actually the revolution, of changes in our body size.

Some events are obvious, like the invention of the automobile and the television, and the progressive price decreases that made these luxury items affordable for the masses.

Others are less obvious but equally important. Like the mass production of tin cans, the invention of frozen food and TV dinners, the first soft drinks and soda fountains, the first vending machines, and the first breakfast cereals with their cartoon mascots and heavy advertising budgets.

Also covered are the invention of fast foods, the introduction of drive-through take-away meals, and the discovery of a way to turn corn starch into a super-sweet syrup.

Some events are especially telling. Like a huge jump in diabetes rates, a rapidly growing market for diet drinks and diet pills, the difficulty of recruiting soldiers who were physically fit, and a US President’s decision that ketchup is a vegetable as a way to reduce pressure to fund more vegetables in school lunches.

Some events are very recent. Like the invention of palm-held computer games for kids, the dramatic increase in portion sizes, also for drinks, in restaurants and, at the end of the previous century, the alarming statistic that 65% of American adults were overweight, including 30% who were obese.

Let me make my point. All of these inventions shaped the social environment. All of these changes in health status were shaped by the social environment. The rise of noncommunicable diseases does not represent a failure of individual willpower. It represents a failure of political will at the highest level.

You cannot hide obesity. It is all too easy to see. You cannot hide the costs of managing extremely demanding diseases linked to unhealthy lifestyles. The costs are way too high to hide. On current trends, no country in the world will be able to sustain these escalating costs much longer.

For all of these reasons, I conclude that political leaders have a responsibility, a duty, to introduce policies that protect their citizens from extremely widespread and extremely well-documented risks to their health. They cannot set aside this responsibility and leave things to be worked out by market forces and so-called corporate social responsibility.

For example, the best way for populations to lose weight is for the food industry to sell smaller quantities of unhealthy food, food that is industrialized, mass produced, cheap, convenient, tasty, and immensely profitable, but deadly for health.

For obvious reasons, this will never happen all by itself.

Ladies and gentlemen, but ladies in particular,

I have a final observation, actually a request. The Women’s International Forum was established to give its members an opportunity to learn. You want to learn, to understand the issues, to grasp the challenges.

I urge you to do so on the issues and problems I have discussed. Women, especially women of your social rank and professional status, have a great deal to say about what people eat.

Michael Pollan, one of America’s most respected food writers, once started an article in the New York Times on healthy eating with some very precise advice.

It goes like this. Eat food. Not too much. Mostly plants. Mr Pollan then takes several thousand words to explain why following this simple advice has become so monumentally difficult.

I urge you to keep digging into the issues. Use good judgment and common sense. Keep in mind: the food industry has no motivation to tell you the truth.

Politicians face tremendous political and financial pressure from powerful lobby groups. Time and time again, national dietary guidelines are watered down at the insistence of these groups.

We all get confused by conflicting studies about what is good to eat that seem to make the headlines every month. Keep in mind, too, that nutrition science is imprecise. The way this science works is to study individual food constituents, but not the admittedly still mysterious ways these components interact when they are present in real food.

Remember the advice: eat food. If some highly processed item is not something your grandmother would have recognized as food, don’t touch it.

In my view, the world’s fragile economy is another factor that supports continued inaction against the root causes of obesity and noncommunicable diseases.

Preventive measures pit public health against the interests of powerful multinational corporations. Any health policy, no matter how badly needed, sound, or far-sighted, that is perceived to threaten a fragile economy, risks being put aside in the drive for economic recovery and a strong GNP.

I can tell you about the pressures, even the threats, that clear and unequivocal dietary advice can provoke. In the late 1990s, WHO gave refined sugar a value of zero as a nutrient. That’s right: zero.

The intention was to let health officials know that, if they have a sub-population or group that consumes no sugar at all, they do not have to worry. An absence of sugar in the diet will never cause a nutrient deficiency or related disease.

This was fully backed up by scientific data, but the result was a true firestorm. After all, no branch of the food industry can afford to score a zero.

As I said, use your common sense. Ordering a diet soda together with a piece of chocolate cake is not what we mean by a balanced diet. In the same way, a breakfast cereal that has added fibre and vitamins, but is loaded with sugar is not the ideal meal for a child.

Remember, too, that according to no less an authority than the World Health Organization, a child who eats no or very little sugar will never suffer from a deficiency disease.

Thank you.