Nutritional Epidemiology

Dariush Mozaffarian, is a cardiologist and public health expert whose work at Tufts University (Boston, USA) focuses prominently on science-based food and nutrition policies aiming to tackle obesity, diabetes and cardiovascular disease in the US and globally. Dr. Mozaffarian, introduced us to how food systems should look in the 21^st century to be able to tackle our current and future challenges, during the Transforming Food Systems session at the American Society for Nutrition (ASN) conference: Nutrition Live Online 2021.

Mapping sustainability for food systems

In the midst of the second year of the COVID crisis, we cannot deny that this is not the only pandemic we are dealing with nowadays. The current global dietary patterns pose a massive risk for developing chronic diseases such as obesity, cardiovascular disease and diabetes. These dietary patterns are thus the source of many of the major causes for death and morbidity worldwide but they are also a key factor in sustainability.

The Sustainable Development Goals (SDGs), proposed by the United Nations in 2015 comprise 17 comprehensive goals set to be met by 2030. Unfortunately, many of these goals are not going to be achieved due to what is still NOT changing with our existing food systems. When it comes to the role of food and nutrition on these goals, the biggest focus is placed on ending hunger (SDG 2) and climate action (SDG 13). Indeed, lack of access to healthy and nutritious food is still a very serious issue in many parts of the world, and 25% of all climate emissions are due to the agricultural and food production sector. But we often forget that food and nutrition can have a direct impact on our overall health and well-being (SDG 3) and not enough focus is being placed on this, which is a “big missing link” as Dr. Mozaffarian called it, since “to think about food systems is really to think about chronic diseases”. 

Additionally, food waste is also a problem not being sufficiently addressed in relation to responsible consumption and production (SDG 12) since our current food systems are contributing greatly to the loss of biodiversity and deforestation. This tendency for overproduction and overconsumption has also placed a great stress on our oceans, affecting the balance and ecosystems below water (SDG 14), which in turn might also affect our access to clean water and sanitation (SDG 6) because most of our water is being used towards agriculture. Food-related businesses have been the most direct way out of poverty (SDG 1) for many communities, whether this is on the production, distribution, or hospitality sectors, which is also an important sector when we want to guarantee a reduction in inequalities and disparities (SDG 10). 

So, in order to have more sustainable agricultural practices and food systems we also need to think creating new routes in terms of innovation and infrastructure (SDG 9), one of the biggest challenges for the future will rely heavily in the reinvention of industries to produce food that is both nutritious, sustainable and profitable. 

As we can see, food and nutrition are very closely intertwined with many of the 17 SDGs. Thus, in order to design the food systems of the future we cannot keep thinking of food as an isolated item. We need to create food-related policies that consider all the complex ramifications that the food production chain has on the SDGs, on our health, and on the global burden of disease and mortality. 

So, what are the new bold innovative actions in food systems that will allow us to meet the SDGs by 2030? And what are the pieces missing to get us there?

Paving the way to the food systems of the future

Dr. Mozaffarian remarks that “to know where we want to go, we need to understand  how we got here”, so to create future solutions, we need to look at how we got to our current food system. 

Our modern food system is a reflection of the legacy of the goals of the 20^th century, which was shaped by two major events. First, the discovery of all the vitamins and their roles in disease development. For the first time it was discovered that a single nutrient could be the sole cause (and cure) for a disease, which of course lead into initiatives that focused of fortification. Second, the population explosion which translated into the fear of mass starvation. This is how the so-called Green Revolution came to be, prompting the mass production of starchy foods that could feed the increasing population. As a result, we have a 20^th century food system that relies on heavily processed foods which are stable for transportation, which are energy-dense to fend off starvation, meaning rich in starch, fat and sugar, and which are fortified with vitamins to avoid single-nutrient diseases. In summary, food designed to ‘treat’ caloric insufficiency and vitamin deficiency.

What we did not realize then, is that these ‘cures’ would lead to more serious chronic problems down the line. Chronic diseases are disabling and killing our population worldwide with conditions including diabetes, heart disease, obesity, cancer, and many others. So now we need to switch into a food system fitted to the needs of the 21^st century, focusing on nutrition equity and sustainability instead. This can be achieved through the four pillars described by Patrick Webb (who was the chair of the session on Transforming Food Systems at ASN’s Live Online 2021 Conference). First, we need to ensure that sufficient nutritious food is available to all and that it has been produced in a sustainable way. Second, we need to improve accessibility by finding ways to move along value chains in a more efficient manner, which can then result in lower costs and less food waste. Third, we need to make sure that healthier diets are affordable, lowering the demand for ultra-processed foods. And fourth, empower the consumers to make informed food choices by increasing the desirability of healthier diets. 

The road ahead…

So, how can we design food systems that will meet the UN’s SDGs by 2030? What are the missing pieces? According to Dr. Mozaffarian, “we are not going to solve the problems of today with the solutions of yesterday”. So first and foremost, we need to find and create new solutions, and to do so we need to invest in science, research and innovation. We need to make huge global investments in both public and private science so that we can expand and improve every field from agriculture and food production to behavior change and everything in between. Then, we need to be able to renovate our current food environments to make them better suited for healthier diets, in particular, we need to transform those places where people buy and eat their food. We also need to emphasize the importance of diet-related chronic diseases, we need to make space to address the increasing amount of people suffering from obesity, cardiovascular disease, diabetes, cancer, and other chronic diseases that are highly linked to overnutrition. 

It is also paramount to re-invent agriculture. New agricultural practices need to focus not only on the production of nutrient-rich and minimally processed foods that can be transported around the world at an effective cost, but also on new ways to mitigate the climate crisis by reducing the impact that our current practices have on the environment. If we are to reach the SDGs, we need to engage the private sector as well as the public, every stakeholder from farming to retail and hospitality industries needs a seat at the table to become part of the solution and not the problem. And lastly, we need to establish true cost accounting; so far we have only focused on how much it costs to produce food and how much it costs to buy it, but moving forward we need to account for additional costs such as healthcare costs, loss of productivity, climate and environmental costs, etc. and here is where governments can play a crucial role in designing and implementing policies that ensure that those economic tradeoffs are accounted in the market.

To be able to move onto a food system designed for the 21^st century, we have to push forward the nutrition science, agricultural science and behavioral science and continue to explore emerging fields (including gut microbiome, personalized nutrition, phenolics and flavonols, food processing, additives, timing of meals or chrono-nutrition, brain health, immunity, allergies, etc.). More importantly, science has to intercept with policy, otherwise this is all stale knowledge. Dr. Mozaffarian remains optimistic that through advancing and promoting science and using science-based nutrition policies we can unite scientists, governments, and the private sector, so that we can transform our food systems to meet our current and future needs together. 

The definition of nutrition has been closely related to health and disease since its inception. However, with the development of the concept of health we have started to associate nutritional science with many disciplines and thus, we have seen the rise of crossovers between nutrition and fields such as genetics, social sciences, anthropology, psychology and behavioural sciences among others. The importance of this multidisciplinary approach to nutrition has been reflected in the very first session of the Nordic Nutrition Conference 2020, where the focus was placed on Food-related behaviours on a changing society. 

Professor Lotte Holm, who teaches Sociology at the Department of Food and Resource Economics in Copenhagen University talked about the changes in eating patterns observed in the Nordics countries over a period of 12 years. Lotte pointed to the close link between meal patterns and societal structures and how our eating habits have evolved with our changing society: from pre-industrial to industrial to our current post-industrial era. Nowadays, our society is heavily marked by phenomena such as globalisation, individualism and flexible working patterns and these have all played an important role in the way we eat. Thus, our current eating patterns should reflect the adaptation to the social hypotheses and constructs of the era that we live in… or do they?

A study designed to explore everyday eating patterns in the Nordic Countries (Denmark, Finland, Norway and Sweden) revealed how, overall, certain trends have remained stable over time. The Nordic countries continue to have core traditional elements in their national food habits and two marked lunch cultures (hot vs cold), as well as a dominant position of meat consumption during dinners. The main meals continue to be simple in their format rather than elaborate, favouring one-course meals and foods that require little to no preparation. 

However, some changes have also come about, inducing the harmonization between food cultures in the Nordic countries. These trends could point towards the increased awareness of healthier eating habits. For instance, water is becoming a more popular drink for lunch and dinners as opposed to sodas and there has been a radical decline in the consumption of cake and pastries associated with the traditional fika culture in Sweden. Also, there has been an increase in vegetarian meals and the introduction of fruits and vegetables in breakfasts and cold lunches, as well as a rise in the consumption of cereals and yoghourts for breakfast. 

Another interesting discovery is the marked unwillingness of the Nordic populations to decrease their meat intake for environmental reasons. In Denmark, this was particularly remarkable as up to 70% of the participants declared that they had not reduced their meat intake nor will they be willing to do so in the future. This might come hand-in-hand, with Denmark’s strong meat production industry and suggest that public health efforts towards promoting a reduction of meat consumption need to be addressed in a more productive way.

Looking at the context in which meals occur, the study discovered that eating still mostly happens at home. Eating alone and in shorter meals (lasting less than 10 minutes) are also increasing trends in Denmark and Norway but not in Sweden. The decrease in formality of meals has opened up for the inclusion of other activities while we eat, such as watching television, listening to the radio, reading, or using electronic devices. Interestingly,  a de-structuring of gender roles when it comes to meal preparation has also been observed in this study, as more men across all age groups, education levels and income have started to take charge of cooking and planning meals.

Overall, little disruption was observed in meal patterns in the Nordic countries. There was a somewhat strong tendency towards individualisation and an even stronger towards flexibilization of meal patterns, as well as an increase in convenience meals, pointing towards commercialisation but not very strongly. Conversely, these trends are much more patent in other countries such as UK where where eating does not happen in peaks but irregularly throughout the day due to different schedules and the wide availability of food at any given time of the day, what is known as ‘the grazing hypothesis’. 

It seems that Nordic food cultures are becoming more and more like each other in certain aspects, although certain national differences remain, most markedly the existence of two clear lunch patterns and the adaptation to personal life arrangements. So, while Sweden and Finland tend to favour hot lunches, Denmark and Norway favour cold lunches. Also, those within the workforce tend to have longer meals with their colleagues, and those who live alone have shorter dinners in a more informal setting and usually combined with another activity, like watching television or using electronic devices. However, Nordic countries do not seem to have absorbed global patterns seen in other countries.

Looking to the future, Lotte expects to see an increase in commercial eating in the form of more meals taking place outside the household and the increase of consumption of ready-made or pre-prepared meals. However, she is also hopeful that with an increasing concern for the environment we might see an inclination to decrease meat consumption, although this seems unlikely especially in Denmark. Nutrition should no longer be considered an isolated concept and it is only through understanding the complex context that surrounds it that we can hope to influence individual choices and governmental policies that affect our eating habits with hopes of a healthier society. 

For more information on the topic you can consult the book Everyday eating: in Denmark, Finland, Norway and Sweden. A comparative study of Meal Patterns 1997-2012 by Jukka Gronow and Lotte Holm (eds), Bloomsbury Academic 2019.