As France takes up the rotating presidency of the Council of the European Union, the debate over the Farm to Fork (F2F) strategy could soon grow heated. The issue the nutrition has become more central to European policymaking than ever, taking on new stakes. And while the planet might be obsessing over the new Omicron variant, we mustn’t forget other diseases, least of all the brewing crisis around the obesity epidemic (especially since, as a growing number of studies show, the two could well be linked).
More than ever, the European institutions need to not just think seriously about how to eliminate this public health crisis, but also take concrete actions to do so. Professor Michele O. Carruba, honorary president of the Center for Obesity Studies in Milan (CSRO) and Enzo Nisoli, scientific director of the CSRO and professor of pharmacology at the University of Milan, are actively engaged in this fight. The two Italian experts responded to the European Scientist’s questions covering their work on obesity and the substantive measures they believe institutional stakeholders could take in response to it, particularly when it comes to promoting a sense of responsibility among consumers via tools such as directives and front of pack (FOP) labelling.
The European Scientist : How do you evaluate the current state of the obesity epidemic in Europe, and how do you feel the situation has evolved since the onset of the pandemic? Have the successive confinements and restrictions imposed on European populations made it easier or harder to maintain balanced diets and levels of physical activity?
Prof. Carruba and E. Nisoli : At least 59% of adults in Europe already live with pre-obesity (i.e., being overweight) or obesity. In the WHO European Region, three times more people are obese today than in the 1980s, and a staggering ten times more children are obese than in the 1970s. In 2006, the EU announced an estimated 7% of health costs were being spent treating cases of obesity, which accounted for 10–13% of deaths in different parts of the Region. Projections made by the WHO state that by 2030, eight European countries (Austria, Czech Republic, England, Estonia, Greece, Ireland, Slovenia, and Spain) will see the prevalence of frank obesity (BMI ≥ 30 kg/m2) exceed 30% of the population. This will lead to an increased incidence of obesity-related disorders, and no national welfare system is equipped economically to support the related increase in expenditures. This is the picture we’re looking at in the short term if action is not taken.
Scientists have an ethical duty to engage governments to act to curb this epidemic. Although recent years have seen a slow but progressive realization by European governments that obesity can be a severe problem for countries’ economic and social development, state policies to date have not been able to make a proper and beneficial impact.
When obesity was first included in the International Classification of Diseases in 1948, hardly anyone took notice. The misconception that obesity is a lifestyle choice, and that it can be reversed simply by exercising willpower, has become cemented in the minds of the general public and much of the medical profession. Still, over the past 25 years and especially in the last decade, momentum has been steadily building towards an acknowledgement that obesity is not merely a risk factor for illnesses such as type 2 diabetes; it is a disease in its own right.
In 1997, the WHO recognized obesity as a chronic disease. In March 2021, the European Commission issued a brief that defined obesity as a “chronic relapsing disease, which in turn acts as a gateway to a range of other non-communicable diseases”. The brief provides obesity with the formal and binding categorization status of non-communicable disease (NCD).
There is still no definitive study that clarifies the consequences of the limitations imposed by the COVID-19 pandemic, except for a few regional studies. Moreover, these small and limited studies focused on the effects of confinements and restrictions imposed on European populations contradict one another.
TES. : What are the main lessons we in Europe have learned from Covid thus far in relation to obesity and its impact on our health as a continent?
Prof. Carruba and E. Nisoli : The COVID pandemic ought to have taught us that obesity is a very severe disease and that people with obesity are more prone to fatal consequences of viral infections.
Individuals with obesity, and particularly those with predominant visceral adipose tissue (VAT) accumulation, are for example at significant risk of developing a more severe form of coronavirus disease 2019 (COVID-19) (1) (2). Several studies worldwide have described the higher risk of infection, intensive care unit stay, and death in people with obesity. Moreover, these subjects produce more respiratory droplets with a higher viral load, and the people with obesity are therefore more infectious than normal-weight subjects. Also, we have recently demonstrated in more than 1,000 subjects that SARS-Co-V2 – the virus that causes COVID-19 – infection-naïve individuals with visceral obesity had lower antibody development over time than individuals without visceral obesity. They reached a lower antibody peak and had a more significant drop in antibody levels at three months after dose 2 of mRNA vaccines (2). This warning effect in individuals with abdominal obesity must also support recent recommendations to offer “booster” vaccines to adults with high-risk medical conditions, including obesity and those with more prevalent abdominal obesity phenotype.
If we disregard existing pandemics such as obesity, the overlapping that occurs when a new pandemic (like the one we currently face) arrives will have severe consequences for an already fragile population. Medical consequences overlap with economic consequences, especially for the most marginalized segments of society (be it economically, culturally and socially), which includes many of the people suffering from obesity. It is well known that obesity is prevalent in the lowest social strata, where lower incomes and education levels dovetail with reduced access to social and health support.
TES. : When you compare the institutional responses to growing obesity rates in Europe to other parts of the world, where do you think European policies are demonstrating success, and where are they coming up short?
Prof. Carruba and E. Nisoli : We particularly welcome the EU Commission’s launch (on 20 April 2021) of the European Parliament’s intergroup on obesity to help national health systems address obesity as a prioritized non-communicable chronic disease. This decision considers the alarming situation of countries such as Malta, Hungary, and Lithuania, which are among the most affected by this obesity epidemic and where the obesity rate stands at 28.9%, 26.4% and 26.3%, respectively, compared to a European mean of 17%. Other EU countries such as Cyprus, Ireland, and Portugal have seen their obesity rate increase almost fourfold in just 40 years.
The relevant point is that European administrative organs have understood that obesity is the cause of potentially fatal diseases, including type 2 diabetes, heart disease, and cancer. According to the WHO, being overweight or obese is the fifth leading cause of death. Among the revelatory examples in Europe: Bulgaria had 125 obesity-related deaths per 100,000 inhabitants in 2017, followed by Romania with 109.7 deaths per 100,000 inhabitants and Latvia with 106.
Moreover, it is crucial for us to realize that the most worrying statistics are those related to children. One in three children in the EU aged between six and nine is overweight or obese, which can increase the risk of them suffering from diabetes, cancer, cardiovascular diseases or dying prematurely.
In this context, it is worth underlining the EU Commission’s launch of its school fruit, vegetable and milk scheme and the Commission’s Farm to Fork strategy that calls on the food and retail industries to increase the availability and affordability of healthy and sustainable food choices. The HealthyLifestyle4All campaign promotes a healthy lifestyle for everyone across all generations and social groups, including children.
These initiatives will have to be implemented and revisited in the years to come. However, although primary prevention is ideal, the tragic reality is that almost 60% of the EU population already lives with pre-obesity or obesity. Therefore, these undertakings by the European Commission’s organs must serve as the start of a collaborative drive to effectively address obesity as a chronic relapsing disease. That requires embracing policy interventions that are prepared to go beyond primary prevention.
TES. : Are policymakers paying enough attention to the relationship between lifestyles and obesity? And if not, what elements of that relationship are they missing?
Prof. Carruba and E. Nisoli : Before anything else, policymakers need to understand that the relationship between lifestyles and obesity is the reverse of generally believed. It’s not necessarily the case that altered lifestyles cause obesity; on the contrary, obesity itself is in many cases responsible for causing incongruous lifestyle changes. Without nutritional education starting in kindergarten, the public as a whole can’t realize the problem at hand.
The approach must therefore be cultural and educational. Policymakers must empower people to prevent obesity and treat it when it occurs. There are many interventions needed in this regard. Examples include the problem of junk food advertising, the lack of outdoor physical activity facilities, policies to integrate people with obesity into the workforce and education, and the lack of or inadequate funding for local social networks.
Our Milan Charter on Urban Obesity, recently promoted by our research center (the Center for Study and Research on Obesity of University of Milan, Italy), is in line with this objective and has been endorsed by the European Association for Study of Obesity as well as by the municipal governments of many large Italian cities (3).
Lifestyle changes are complicated to achieve and promote at the individual and population levels. Proper changes will be possible only when the prevailing economic and political wisdom fully appreciates that health costs are impossible to sustain without measures to prevent non-communicable disease – and obesity is unquestionably a major one.
TES. : We are seeing a worldwide shift in attitudes towards saturated fats, which are no longer perceived as an evil the way they were starting in the 1950s. The truth about fats and their relationship with CVD has been acknowledged by countries like Sweden (in 2016), while Time magazine had its “Eat butter” cover in 2014 and an increasing number of “LCHF” (low carb, high fat) diets enter the mainstream. Where do you see the EU’s current position in relation to this paradigm shift?
Prof. Carruba and E. Nisoli : Our impression is that the European community is belatedly realizing that the most recent literature (supported by four meta-analyses, all saying essentially the same thing) has changed – or, rather, is changing – the attitude towards saturated fats, specifically toward their relationship with cardiovascular risk.
The most recent data seem to exclude the possibility that the consumption of these fatty acids, if they are mainly derived from milk and milk products (like cheese), is associated with an increase in the risk of cardiovascular events. Indeed, in many studies, the opposite is true, and we see a significant reduction in the incidence of these events. This fact is at odds with the long-held conventional wisdom that all conditions that raise plasma cholesterol levels (and saturated fats indisputably raise plasma cholesterol levels) increase coronary risk. It is evident, though, that the absence of a correlation with cardiovascular events is more important than the presence of an effect that increases plasma cholesterol levels.
Since cheeses are among the primary sources of saturates in the European community, it is reasonable to hypothesize that recommendations for EU citizens to reduce their dietary intake of these fatty acids will almost automatically penalize the consumption of cheeses without securing significantly favourable results in return.
It is also well documented that replacing saturates with carbohydrates, especially those with a high glycemic index, in no way positively and beneficially impacts cardiovascular risk. Instead, the reduction in saturated consumption, if not adequately “controlled” by experts, will lead to important changes in habits of the consumer (which should be avoided if possible) without any significant benefit in terms of health.
TES. : Amidst the ongoing debate over nutritional labeling and dietary information directed at consumers, the Carapelli Nutritional Institute (where you preside over the scientific committee) recently held a roundtable discussion about the competing Nutri-Score and NutrInform labels. How do you assess the two labels and their utility for informing consumers?
Prof. Carruba and E. Nisoli : As medical experts in the treatment and prevention of obesity, we jointly and critically analyzed the limitations of an oversimplified approach to a highly complex and multifactorial disease. We firmly believe that the Nutri-Score system should be studied further compared to different FOP labels, particularly the NutrInform Battery system — which was only recently rolled out — for its effectiveness against obesity.
The Nutri-Score system has many limitations and shortcomings. To list just some of the examples:
1) It oversimplifies nutrition by distinguishing foods into good and bad, whereas in reality, individual foods are not only or always good or bad; their effect also depends on the quantity and daily or weekly frequency with which they are consumed;
2) It does not take into account the portions of that given food which are consumed;
3) It does not allow for the gradation of the daily consumption of different components of a person’s diet;
4) It does not provide helpful indicators to people with specific nutritional needs. Individuals with high cholesterol levels will not be able to judge their daily consumption of saturated fats, while individuals suffering from hypertension will not be able to evaluate their total consumption of sodium. People with diabetes, for their part, will not be able to assess their consumption of simple sugar in meals.
That is why our position paper (4) — endorsed by the principal Italian scientific societies focused on nutrition — aims to draw attention to the novel NutrInform Battery labelling system as a more educational approach. As we sought to illustrate in our article, the concept behind the NutrInform Battery and the process of developing it built on scientific evidence to produce a system with a higher level of flexibility and, potentially, more capacity to inform consumers.
TES. : In looking for the perfect solution, European Union seems to be facing two issues: avoiding the pitfalls associated with a “one size fits all” approach, while also steering clear of a decision which could alienate the rich gastronomic traditions of EU countries. What recommendations would you make to EU stakeholders in overcoming these two obstacles?
Prof. Carruba and E. Nisoli : To answer this critical question in a non-superficial way, we must return to the fundamental underlying question: how can we intervene from a regulatory and organizational point of view to promote correct and healthy food consumption? This topic includes medical and epidemiological considerations and, above all, organizational, economic, educational, and political ones. What kind of diet should we be encouraging?
Countless studies show that consistent adherence to the Mediterranean diet prevents metabolic diseases, such as obesity and type 2 diabetes mellitus, atherosclerotic cardiovascular diseases and various types of cancer, as well as neurodegenerative diseases such as Alzheimer’s dementia.
But how can we reconcile the dictates of this type of diet – which includes significant consumption of unrefined carbohydrates with a low glycemic index, vegetables and fruit for their fiber and anti-oxidant components, and extra-virgin olive oil for its high polyphenol content – with different culinary habits and cultures, or with the industrial production of raw materials and processing, as well as large-scale distribution, the cold chain, transport, etc.?
Those questions make it clear that the problems we need to address are complex and intertwined with many aspects of our daily lives. Our political systems (which should direct the economy and not the other way around) are responsible for the health of the citizens, who entrust them with the organization of our societies.
It is worth emphasizing that the European community needs to take decisions to reconcile health, economy, and trade issues not just between different countries but also between different cultures and traditions. We recommend European stakeholders invest in promoting and monitoring lifestyles, including physical activity and nutrition, to prevent non-communicable chronic diseases with this context in mind.
In the field of nutrition, food labelling can play a positive role. It would be worthwhile for the European Union to assess, in a process free from political and economic pressure and influence, the actual capacity of the various labelling systems to promote greater awareness and competence concerning nutritional issues among different European societies. There are no such thing as good or bad foods, but instead inappropriate types of consumption in terms of quantity and quality (combinations of different foods in the daily diet). We believe the NutrInform Battery system meets these needs better than the Nutri-Score.
TES. : Beyond nutritional labels, what other tools do European citizens and public health bodies need to effectively reverse rising obesity rates?
Prof. Carruba and E. Nisoli : Beyond awareness of the fact that obesity is a disease and that, in many cases, it can be severe enough to impact the quality of life, reduce lifespan, and cause death, Europe as a whole needs to prioritize prevention and treatment and make significant investments in research and in promoting healthy lifestyles. Without in-depth education starting in early childhood – indeed, from the womb, with increased awareness among mothers planning a pregnancy – we will not even achieve our minimum objectives in the fight against this pandemic, which will last far longer than COVID-19.
(1) Földi et al., Obesity 29: 521-528, 2021; Iacobellis et al., Obesity 28(10): 1795, 2020
(2) Iacobellis et al., Obesity 28(10): 1795, 2020
(3) Malavazos et al., Obesity. 2021 Nov 30. doi: 10.1002/oby.23353
(4) Carruba et al., Obesity Facts 14: 163-168
(5) Carruba et al., Eat Weight Disord. 2021 Oct 19. doi: 10.1007/s40519-021-01316-z
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