Abstract
Recent editorials and commentaries in the anniversary volume of the Food and Nutrition Bulletin described the remarkable 40-year history and advances of the journal, its contributors, and its editors. In the first issue of volume 1, James Hester, Rector of the United Nations University, specified that the Bulletin should “…serve an important function by communicating objectively on all aspects of global malnutrition problems and the broad programmes and new areas of activity needed for combating them…making available technical information and specialized knowledge related to world hunger data….” 1 The current statement of mission, aims, and scope adds “…policy research and analysis examining multidisciplinary efforts to alleviate global hunger and malnutrition,” with a focus on the developing world. 2(p1) As documented by the Global Burden of Disease study, hunger and malnutrition remain persistent, vexing problems in much of the world today even as diet-related chronic disease and risk factors have emerged and grown to epidemic proportions globally. 3
In this commentary, we begin by briefly examining chronic disease research published in the Bulletin since its inception. Next, we pose key issues for future research, drawing on the framework of the core functions of public health—assessment, assurance, and policy development. 4 Most research to date focuses on assessment and much remains to be done to further strengthen methods for assessing nutrition and chronic disease in diverse populations and settings. Yet moving beyond assessment will be critical to translate such precious data, including existing data, into action—interventions to reduce not only the immense global burden of diet-related risk factors and chronic disease but also continued, persistent undernutrition, stunting, wasting, and micronutrient malnutrition.
Background
In a remarkable chapter entitled “The emergence of diet-related chronic diseases in developing countries,” Stein and Martorell described the nutrition transition, its determinants, relation to economic development, underlying mechanisms, and public health significance, especially for populations also experiencing persistent undernutrition. 5 In this section, we examine how select contributions during the Bulletin’s 40-year publication history contributed to awareness of this immense global challenge and potential solutions.
Interestingly, in the very first issue of the Bulletin, in 1978, contributors to the News and Notes section recognized that in conducting an objective review of global data on breastfeeding, it would be necessary to consider the role of breastfeeding in “…health problems in industrialized countries, such as obesity, coronary heart disease, and allergies.”
6(p1) In fact, Instituto de Nutricion de Centro America y Panama (INCAP) investigators including the Bulletin’s first editor-in-chief, Dr Nevin Scrimshaw, had already initiated studies of atherosclerosis and coronary heart disease in the early 1950s.
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In a key 1981 paper, Pellett noted that As wealth increases within a developing country, sections of the population become prone to the diseases of the affluent. Obesity, atherosclerosis, diabetes and other diseases are increasingly significant in oil-rich nations and also among the rich sections of some of the poor nations. So that public health and nutrition consultants may be faced simultaneously with nutrition problems related to poverty and affluence. This is obvious and is an expected consequence of development.
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In the 1990s, key publications documented these trends, particularly the rapid global spread of obesity along with persistent undernutrition and malnutrition. 12 -15 In a January 2000 supplement with the aspirational title “Ending malnutrition by 2020: An agenda for change in the millennium,” key global nutrition challenges were identified as “adult chronic disease accentuated by early undernutrition” and “obesity rates escalating,” in addition to undernutrition and micronutrient malnutrition. The report concluded that “coherent community-based policies can transform the burden of adult chronic disease,” based on experience from Norway, Finland, and other countries. 16
In December 2001, the Bulletin published a major supplement on the nutrition transition. Papers in this volume summarized nutrition trends, policies, and strategies in Asia and the Pacific; presented case studies for the People’s Republic of China and Sri Lanka; and outlined programs and policies to address epidemic diet-related chronic disease in the region. 17 In January 2003, the first issue of Dr Irwin Rosenberg’s tenure as editor-in-chief, the Bulletin published summaries of 2 major policy pieces, the World Health Organization (WHO) Global Strategy on Diet, Physical Activity and Health and the joint WHO/Food and Agriculture Organization Expert Report on Diet, Nutrition and the Prevention of Chronic Disease. 18 The following year featured papers from a Pan American Health Organization regional consultation of the Americas on diet, physical activity, and health, including a proposed public health framework for chronic disease prevention and control and related food and agriculture policy issues. 19
In 2005, the Bulletin reprinted Haddad’s discussion about how food policy could help redirect the diet transition, namely, “…the transition from acute disease to acute plus chronic disease,” with both demand- and supply-side interventions. 20 Similarly, a 2007 special issue on linkages between agriculture and health included a paper by Hawkes, identifying agricultural policy levers. 21 Tzioumis and Adair noted in 2014 that “The dual burden may manifest in a community, household, or individual, but these levels have not been addressed collectively.” 22(p230) Their comprehensive review and evaluation of the world’s literature (since 1990) on dual burden—from determinants to distribution—is a compelling call for action. 22
Increasingly prevalent global overweight/obesity and dietary risk factors, often occurring at young ages, are now recognized as major contributors to an ever-growing global burden of chronic diseases. 23 These diseases are complex and costly to manage, consuming a substantial, growing part of budgets for many countries, some still experiencing concurrent undernutrition. Over the past 15 years, many publications in the Food and Nutrition Bulletin have described stunting, malnutrition, obesity, dietary intake, food patterns, and chronic disease risk factors in diverse samples (some nationally representative, often subnational or convenience samples), using varying approaches for assessment and analysis, to describe the dual burden of malnutrition in populations. Yet despite the plethora of published recommendations, particularly for policy, very few papers describe interventions that have been implemented and evaluated. Having briefly explored the development of this field over the past 40 years, as seen through the lens of the Food and Nutrition Bulletin, we now offer some thoughts on future directions for research to inform prevention and control of chronic, noncommunicable disease in low- and middle-income countries.
Future Directions for Research
The science of describing and identifying diet/nutrition problems is far more advanced than the science of identifying effective solutions. This is a major limitation to addressing nutrition-related chronic disease globally. The Bulletin’s long-standing goal of increasing nutrition science capacity, translation, and leadership in low- and middle-income countries can contribute here, as could support for establishing strong cohort studies in sentinel sites worldwide.
There is an urgent need for improved dietary epidemiology and surveillance. Traditional approaches to dietary assessment focus on dietary recalls/records and food frequency questionnaires. These established methods have varying strengths and limitations, depending on the specific research question, but all are time/labor intensive, to the point that, at times, completion of the assessment becomes the goal, rather than using the analytic results to inform or improve health programs or policy. New technologies enable tracking enormous quantities of data and could be harnessed to track nutrients and other dietary components in near real time not only to learn more about association or causation, but most importantly, to provide solutions to improve diet. These new approaches could also lead to stronger local data, compelling for the public and policy makers, to identify and address diet and health disparities. Local data and local solutions can be very convincing for decision makers and can also be translated to inform interventions in other locales and settings.
Consumers are accustomed to rating products with a star system and using these ratings to inform purchase decisions. Developing a “universal” system, continuously updated based on new science, for evaluating strength of evidence for associations between dietary components and health outcomes could help assure credibility of dietary recommendations and, if used to inform funding decisions, increase the health return on research investments, assuming fiscal resources will continue to be limited. For example, funding might be directed to uncertain but promising dietary factors associated with priority health outcomes for a country or region, rather than to established, well-studied associations. Rigorous methods to identify, review, and score the evidence will be critical, as will commitment to ongoing monitoring. Such an approach might also help prevent public confusion and strengthen credibility as dietary recommendations evolve, based on better evidence.
One can envision a similar system to evaluate the strength of interventions, whether programs or policies, that captures different components of the interventions and the underlying populations, including health status, risks, determinants, and other factors (physical activity, environment, economics, etc) to inform implementation of interventions in other settings. For example, an intervention for Togo, or at least part of it, could be based on a solution developed for populations in Beirut or rural California. Existing resources, such as the Cochrane reviews 24 and the Community Guide, 25 are helpful but tend to examine single nutrients or dietary components and emphasize controlled randomized trials rather than other types of evidence, which can reduce their usefulness for settings that are resource constrained.
In addition to addressing the impact of the nutrition transition on overall disease trends, including intergenerational effects, factors such as rapid climate change will likely affect our nutritional future through impacts on the agricultural sector, including changes in crops, inputs, economics, and, ultimately, food availability. Environmental impacts, land use, carbon footprints, and sustainability will increasingly drive food choices and dietary patterns. A recent modeling study demonstrates how focusing on specific behaviors and risks, including diet, could change the global disease burden over the next 20 years. 26 Such alternative scenarios suggest that the pattern of epidemiologic transition to endemic chronic disease need not be inevitable for low- and middle-income countries. Data on the social and economic costs of interventions and their return on investment should help gain support from policy makers and the public.
Conclusions
From a demographic perspective, a “generation” is considered to be about 20 to 30 years. Thus, the Food and Nutrition Bulletin, at age 40, is now well into its second generation. Its readers and contributors, having made solid gains in reducing the burden of malnutrition and undernutrition, continue work to reduce and eliminate them. However, a larger challenge has emerged during this period, the emergence and devastation of endemic diet-related chronic disease in populations undergoing the epidemiologic transition. If not addressed effectively, this challenge may slow development, lead to its own magnification through intergenerational effects on chronic disease risk, and even undermine progress in eliminating malnutrition. The tools needed go beyond assessment, the focus of so much work in nutrition, to the development of effective and efficient interventions, including policy interventions as well as interventions in communities and clinics. Demonstrating intervention effectiveness will not be enough; these solutions must be translated, disseminated, and implemented widely, at the population level, with assurance that needed services are delivered and sustained by effective policies.
In 2055, a scientific generation or 2 from today, it is our sincere hope that the future readers, contributors, and editors of the Food and Nutrition Bulletin will celebrate its diamond jubilee by reflecting on their collective achievement in alleviating diet-related chronic disease in addition to eliminating hunger and malnutrition globally.
