The Double Burden of Malnutrition GCHB 6780 Roger Shrimpton John Mason Lisa Saldanha

1. The Double Burden of MalnutritionGCHB 6780Roger ShrimptonJohn MasonLisa Saldanha 06 February 2012 Class 7: Causes of DBM III (Physical/Built and Socio-cultural Environment )

2. Content • Midterm test • Physical/Built Environment • Rates and effects of urbanization • Importance of physical activity for energy balance • Rates of adequate physical activity • Socio-cultural Environment • Effects of urbanization • Teenage pregnancy • TV advertising • Conclusions • Readings

3. Mid-termTest • the exam will be emailed to you on Thursday afternoon.  • You'll have a window of 24 hour to complete it and email it back to me (copied to Lisa). • The exam is “open book” with 10 questions, each requiring a short “3-5 line” answer (which can be bullet points) • The exam will be based on the lectures and readings we've covered so far and the relevant pages of the DBM draft.

4. The Physical/Built Environment Half of global population is already urban and two thirds will be by 2050, mostly in today's LMICs

5. The Physical/Built Environment • Throughout the world, technology, urbanization, increasingly sedentary work environments and automobile-focused community design have engineered much physical activity out of daily life. • With urbanization people expend less energy getting to work (sat in car or bus), at work (sat at a desk or stood in a shop or factory as opposed to digging or ploughing in a field) and in the home (electric stoves, vacuum cleaner, and TV watching) • Space to exercise in, be it through walking, biking or playing games, may be difficult to find, especially in the poorer urban districts.

6. The Physical/Built Environment In the US a tipping point in energy balance seems to have happened in the sixties ENERGY BALANCE TIPPING POINT Food availability in the USA 1910-2006 Source: Swinburn et al 2011. Lancet Obesity Series 1

7. The Physical/Built Environment • Energy balance depends on regulating intake and expenditure • The key variable of energy output is the degree of physical activity • Sedentary adults BMR = 60%, TEF =10%, PA = 30% • Very active adults: BMR = 40%, TEF =10%, PA = 50% Source; WHO 2000

8. The Physical/Built Environment Physical Activity is an important determinant of body weight and protects against CVD • Regular moderate physical activity (brisk walking) 60 minutes a day is associated with a lower risk of weight gain • Preventing weight gain after weight loss requires 60-90 minutes of moderate physical activity a day • High levels of fitness protects against mortality from cardiovascular disease and diabetes at all levels of BMI (i.e. even in those that are overweight/obese) • Regular exercise increases the capacity of muscles to use fat rather than sugar (glucose) during physical activity Source: WHO 2003

9. The Physical/Built Environment Exercise in USA

10. The Physical/Built Environment Global age standardized prevalence of insufficient physical activity in adults 15+ by region and income group in 2008 Between a quarter and a half of adults globally don't get enough exercise Source: WHO 2010 NCD Status Report Insufficient weekly physical activity = <5x 30 mins moderate or <3x 20 mins vigorous activity

11. Prevalence of insufficient activity in the Indonesian population above ten years of age in 2007, by age group Riskesdas 2007

12. The Physical/Built Environment Source Hallal et al 2012

13. The Physical/Built Environment • In most developed countries the majority of adults dont use any form of active transportation • Most active are Holland and China • Least active are Australia, Switzerland USA and Brazil. Source Hallal et al 2012

14. Bike lanes can have a positive impact in creating a healthy neighbourhood. • This study examined the impact of building new bike lanes in New Orleans to determine whether more people were cycling on the street and with the flow of traffic after bike lanes were built. • Through direct observation of one intervention and two adjacent streets, observers counted cyclists riding on the street and sidewalk, with and against traffic, before and after installation of the lanes. Data were tallied separately for adults, children, males, females, and by race for each location. • There was an increase in cyclists on all three streets after the installation of the bike lanes, with the largest increase on the street with the new lane. Additionally, the proportion of riders cycling with traffic increased after the lanes were striped. Source: Parker K M, Rice J., Gustat J, Ruley J, Spriggs A, Johnson C 2013

15. The Physical/Built Environment Is walking to school associated with improved metabolic health? • Participants were 229 adolescents, selected through consecutive sampling from Porto, Portugal. • Means of transport to/from school was accessed by asking: ”How do you usually travel to school?” Total physical activity was obtained with an accelerometer for 7 consecutive days. Lipid profile, waist circumference and blood pressure were measured by standard methods. • Walkers have higher odds of having a better WC and HDL-C profile than children who use passive means of transport to/from school, after adjusting for MVPA and diet. Source: Pizarro et al

16. Causes of DBM:The Socio Cultural Environment • Socio-cultural influences • the cultural values handed down from generation to generation • the education system and the “new knowledge” it brings • the media with the food industry spending US$40 billion a year on advertising food, mostly ultra-processed and especially to children and youths • Individual psychology • Peer pressure (to buy this, or to own that) • Immaturity of adolescent brain

17. The Socio Cultural Environment • Examples of socio-cultural influence on the DBM relate to issues such as child marriage which affect maternal and child undernutrition rates, as well as child food consumption and activity patterns, which can affect adolescent overweight rates • Teenage pregnancy rates tend to be higher in rural areas of LMICs than in urban areas, especially if girls school completion rates are higher in urban areas.

18. The Socio Cultural Environment The intergenerational cycle of growth failure is accentuated if teenage pregnancy rates are high Source: SCN 1992

19. The Socio Cultural EnvironmentChild marriage rates by region and rural/urban areas Source: SCN 2010

20. The Socio Cultural Environment Median age first marriage and low birth weight rate by region Source: SCN 2010

21. The Socio Cultural Environment • In urban areas more people travel to work and eat more away from home with increased snacking of processed (convenience) foods • The food industry spends US$40 billion a year on advertising, most of which promotes the consumption of ultra-processed foods. • Transnational soft drink and fast food companies market their products extensively worldwide, especially to children and youths.

22. The Socio Cultural Environment • There are many studies showing that hours spent watching TV are related to the degree of risk of being overweight and/or obese • Whether the risk of TV watching is the lack of exercise or the exposure to advertising for energy dense processed foods is less clear, but likely to be a mix of both.

23. Causes of DBM:The Socio Cultural Environment Socio-cultural influences • Indonesian children are heavy viewers of television, glued to the screen more than 26 hours a week, or nearly four hours a day • A multi-country survey of the influence of television advertisements on children, which included Indonesia, reported that advertising to children was widespread across the countries surveyed, and that while all six countries had common core food-based messages in national nutrition guidelines, the diet actively being promoted on television in all countries goes in the opposite direction.

24. Causes of DBM:The Socio Cultural Environment Socio-cultural influences • For Indonesia it reported that 16% of children watched over 8 hours of television a day, and that for each hour of children’s programming there was 15 minutes of advertising, of which food advertising was dominant. • The majority of children in Indonesia loved watching TV adverts (61%), which they thought informed them about product quality/features (75%) and updated them about new products (91%). • While 75% of parents in Indonesia based their buying decisions on their own judgement, and only 33% said these were influenced by adverts, 58% said they were influenced by their children

25. Techniques targeting Latin American children (3Ps)* • Promotion • Advertisements: build “emotional connections” e.g. from Argentina (1998)- families enjoying soft drinks during meal times to “encourage families to make the brand part of their mealtimes” • Sales promotions: encourage repeat consumption e.g. in many countries (1997-9), collecting bottle caps in exchange for “Hielocos” toys, specifically targeted at 5-12 year olds • Internet: websites with interactive games * Source: Hawkes, C. Marketing Activities of Global Soft Drink and Fast Food Companies in Emerging Markets: a Review: In Globalization, diets and noncommuniable disease. Geneva: WHO, 2002 (http://whqlibdoc.who.int/publications/9241590416.pdf)

26. Techniques targeting Latin American children • Public Relations • Music, event, sports sponsorship e.g. sponsorship of “Copa Coca-Cola” a youth football tournament involving thousands of teenagers from all over Latin America • Philanthropy “We are a good citizen in the country in which we are operating, but it goes beyond that. We want to reach that part of the consumer’s mind, where he feels like a good citizen by buying a product from a socially-conscious company.” (Coca-Cola Mexico, 1997)

27. Techniques targeting Latin American children • Place • Everywhere! “100 Meters Program” by soft drinks company - “No-one should have to walk more than 100 meters to buy our products” e.g. taxis, vending machines, kiosks, festivals • Schools: “Schools Program” to “increase consumption in schools” e.g., focus in Mexico and Colombia selling products in schools in “attractive combo” packages; in Costa Rica on “creating new points of sale in strategic areas of each institution”. Result: increased sales to school children by 50% • Rural areas: Distribution and basic signage most important form of marketing

28. Aims and Content • Aim • to increase consumption of food “brands” (e.g. Coca-Cola) but also food “categories” (e.g. soft drinks) “We are not looking into soft-drink share, we are looking into stomach share,” soft drinks executive, Mexico 1997 • particularly powerful in unsaturated markets, like many Latin American countries • more types of people to consume product • more frequent consumption • more at one time • Content • Most food advertising targeted at children and youth is for high energy, nutrient-poor foods

29. Effects of Food Marketing to Children: Results of Two Systematic Reviews • Food Standards Agency, UK (2002) • Evidence shows that food promotions influence children’s food preferences, purchases, behavior and consumption for both brands and categories • National Academy of Sciences, USA (2006) • Evidence shows that, among children aged 2-11, TV advertising encourages preferences and requests for high-calorie, nutrient poor foods (strong); • influences short-term consumption (strong); • influences usual dietary intake (moderate); • is associated with increased BMI (strong), but this could be because heavier children watch more TV

30. The Socio Cultural Environment • The brain is not fully mature until 25 years of age • Adolescents are not yet fully able to make “rational” decisions, and are much more influenced by “emotional context”.

31. The Socio Cultural Environment • Many of the people in urban areas, and or outside the home and/or on the streets are children and adolescents, and adverts target them especially, when as described in the previous slide their ability “to decide” is not yet fully mature • Many national authorities have banned advertising, be it of foods or non-food items, directed at children.

32. Conclusions The world is becoming increasingly urbanized and consequently increasingly less physically active Between and ¼ and a ½ of adults globally are not “sufficiently” active Only moderate physical activity (walking briskly for at least half an hour) can help protect again becoming overweight, as well as reduce the risks of metabolic complications in those already overweight and obese. There is a great need to ensure that the physical/built environments of urban areas are conducive to increasing physical exercise Socio-cultural factors can also influence both over and undernutrition, through changing cultural values as well as influencing personal choices about food consumption and taking exercise Teenage pregnancy rates are an example of cultural practices that can increase risk of constrained growth from conception to two years. The food industry spends billions on advertizing processed foods, and TV watching increases the risk of getting less exercise as well as consuming more energy dense processed foods.