Out of the Box

Isn't your column a bit … political? I have been asked. Sure. Public health is political, in the sense of the word in Romance languages, meaning policy as well as politics. Bear in mind Rudolf Virchow who, aged 27, was told by the rulers of Prussia to check out an outbreak of typhus in Upper Silesia. In his report he indicted the government, stated that the disease was caused by squalor and misery, and advocated radical economic and educational reform. Weeks later the 1848 revolution broke out¹. He said: ‘Epidemics are great warning signs, against which the progress of civilisations can be judged’. Consider that, as we anticipate the pandemic of childhood obesity and early-life diabetes.

This month I report from Hobart in Australia, and from Santiago in Chile. I propose we should learn from the methods and success of environmentalists who have established that climate change is for real. Then I suggest that before we accuse others of taking the industry dollar, we should take a look at ourselves.

The law of returns

First, happy news. The great thing about the election of Bush II, said a friend in 2000, is that things will get better; but first they will get worse. He repeated this pendulum theory of human affairs in 2004. It seems to work. Perhaps things started to get better the moment this spring when Paul Wolfowitz ascended an elevator at the World Bank in Washington DC with a female employee and chatted to her, asking what the blue ribbon she was wearing meant. ‘This shows that I am a member of the campaign to get rid of you’, she said². Imagine that, two years ago.

The president of the USA appoints the president of the World Bank; and also the chief executive of UNICEF, now Ann Veneman, previously a Bush II cabinet member as secretary of agriculture. Last year she also became chair of the UN System Standing Committee on Nutrition. She seems to have lost interest; Denise Coitinho, head of the nutrition group at WHO, now SCN vice-chair, presides over most of its meetings.

As another brick in the wall, Prime Minister Gordon Brown has made a master of the universe: a cabinet minister, with responsibility for Africa, Asia and the UN system. This is Mark, oops Sir Mark, oops Lord Malloch Brown, previously head of external relations at the World Bank under Jim Wolfensohn³, then head of the UN Development Programme, who later when deputy to UN secretary-general Kofi Annan denounced John Bolton's mauling of the United Nations⁴.

At the same time, the point of climate change has now tipped. The public mood has shifted, as it did with cigarettes and cancer decades ago. Tacitly as well as explicitly, it is now generally accepted that human activity is heating the planet⁵. US polls indicate that if Al Gore ran for office, which he just might, he would get the Democrat nomination and so become the first US president since Theodore Roosevelt to take the whole living and physical environment seriously. Specialists in public health nutrition better had be part of this shift in thinking.

The weather in Australia

Australians occupy a remarkable number of seats on panels charged with strategic thinking about the future of the world. Be in Australia and it's easy to see why. Its scale is awesome. Enterprising Australians are in touch with nature. Some, like Colin Butler of the Australian National University in Canberra, have made their homes in forested areas, and commute to the cities. Almost all the white population lives near the ocean, and many are sensitive to their impact on the Aboriginal population^{6, 7}.

I was in Australia at the end of May. Tony McMichael and I had been invited to give the keynotes at the 25th annual conference of the Dietitians Association of Australia (www.daa.asn.au) this year in Hobart, on the theme of ‘Crunch Time’ – the need to see the big social, political, economic and environmental picture. This was far-sighted of the DAA, headed by Julie Hulcombe and Claire Hewat, and in Tasmania by Judy Seal.

The conference was superbly organised. In three days over 100 presentations were given. Almost all the delegates turned up at breakfast sessions starting at 7 in the morning. I had three jobs; as well as plenary presenter and workshop facilitator, I was cast as ‘hypotheticals’ compère, with an expert panel chaired by Green senator Christine Milne, to see if Australian dietitians want in to political action to protect the planet. They do.

Hardly a surprise – in Australia climate change is hitting home. I talked with dietitian Kay Silvester who also with her family owns an olive farm. In 2006 she had a crop of 2.4 tons; in 2007, 100 kg. Why, was chaos weather: too hot in October, frost in November. It's this awareness that explains why the magazine in my Sydney Holiday Inn featured environmentalist Tim Flannery, 2007 Australian of the Year, on its cover^{5, 8}.

Calories out, energy density up

Here is a riff on Australian nutrition labels. Don't skip, it's interesting, really. Trust me.

Imagine me in room 1214 of Hobart's ***** Grand Chancellor Hotel, fielding email at wallabyfart before the final day of the DAA conference. I am ravenous and there is nothing I would eat in the mini-bar, so I am sampling the organoleptics of Cheerios, kindly donated to delegates by Nestlé. I report that this reconstituted whole grain corn, oats, rice, barley and wheat, extruded into Os, is scrummy. The nutrition label lists 6.5% added sugar, as well as sprinklings of vitamins to prevent outback outbreaks of beri-beri, pellagra and pernicious anaemia.

But the label includes no mention of the DRV (daily/dietary reference value) or is it RDI (recommended dietary intake) for energy. A 30 g serving, neat, delivers 468 kJ/110 kcal, and 100 g deliver 1559 kJ/368 kcal, which makes this stuff more energy-dense than chump chops. The packet says ‘made in the United Kingdom’. The Os or the box?

Then I notice something odder. The previous day I had snaffled a Nestlé goodie bag in the shape of a snazzy red-and-black branded backpack, which delegates may pass on to the children in their lives. The treats inside included 100 g of Club Noir Intense, a 70% Nestlé chocolate imported from Switzerland. The nutrition label lists the minimum polyphenol content in epicatechin equivalents. The label also told me to ‘enjoy slowly, with a sense of ritual’, so alone in my room I wolfed it, in the interests of research and my epicatechin status. Hm, I thought, how many minutes do I need to spend on the rowing machine in the hotel's fitness centre to get rid of that lot? So I looked at the label. Serving size 20 g (hah!), and the whole thing 2320 kJ.

But no kcal content. Could Nestlé have made a mistake? Unlikely. So I ferret through the shelf above the mini-bar where the management places little somethings with eye-watering prices. I find Go Natural's Nature's Super Foods Brazil Nut Walnut & Date bar; Red Rock Deli's rough cut chips/crisps; and Nobbys (‘nibble Nobby's Nuts’) peanuts, a PepsiCo product formulated to be Hi Oleic.

I rummage in my backpack and find Uncle Toby's Plus Protein Mix (official breakfast cereal for the 2007 national swimming championships); and Nesquik Plus strawberry flavour powder, with the Australian National Heart Foundation ‘tick’, I suppose because it is made with low-fat milk, while delivering 73.5 g of sugar per 100 g of kiddie-glop.

None of these energy-dense products lists energy percentages of DRV/RDI; none lists kcal content. Only the kJ content. I raid the mini-bar. I can work out that Pepsi, whose serving size is 250 ml of the 300 ml bottle (what do you do with the other 50 ml?) delivers 100% of its energy from sugars, because it contains 0 protein and 0 fat; whereas Pepsi Max is sweetened with chemicals #950 and #951. But calories? No mention.

Yet Gatorade Fierce Berry, which Cadbury Schweppes supplies to the Australian Institute of Sport, Cricket Australia, and Netball Australia, does list kcal as well as kJ, as does Spring Valley orange juice; whereas Berri tomato juice, and Hartz Tasmanian Lemon and Lime mineral water (plus sugar), do not. There is of course no mention of the energy content of the wines and beers; or of the 5% alcohol tins of premixed Smirnoff Premium Ice, Gordon's G&T, Johnnie Walker Red Label and Dry, or Jim Beam Kentucky Straight and Cola.

Uses for useless information

Why is the calorie content of Australian processed foods and drinks disappearing? And is this a transnational trend? I watch the Pride of Tasmania ferry from Melbourne dock in the harbour overlooked by my room, get on my kit (my research responsibilities do not stretch to nicking the mini-bar vodka, gin, whisky and bourbon), and take off for the hotel health centre. I had googled the kcal/kJ equivalents, and reckoned I could burn off my Club Noir Intense if I averaged above 660 kcal an hour, as usefully calibrated on the US-made rowing machine, for 50 minutes.

Food and drink companies often include freephone helpline numbers on their product labels, but I do not have to dial Bangalore for the amazing disappearing calorie, because I am at a conference of dietitians. So, out of the gym and into the arena, and I ask: Why do nutrition labels on most processed foods and drinks in Australia not list calories, and not specify percentage of energy? (Now I revert to past tense). ‘Good question’, said Roger Hughes, one of the editors of this journal. ‘Not sure I know the answer’.

Fair enough; he is a nutritionist. Dietitians John Coveney and Glenn Cardwell set me right. Australia went metric in 1976. ‘Australians are eager to embrace new technology’, said John. He explained that the international SI system does not include kcal. He said that only the USA, Burma and Liberia have not gone metric.

But, I said, kcal is metric. Besides, how come there is no reference to the percentage of energy on most labels? John said that the SI system has been adopted by Australia ‘not to be useful, but as a scientific standard’. Oh. Ah. Labels in Australia had the dual kJ/kcal information until into the 1990s, when kcal faded out. Now, manufacturers have to include kJ but need not include kcal. So most of them don't. Manufacturers in Australia can also decide the serving size of their products.

I asked the same question of a group of three dietitians. Two took off; the third spoke but said she preferred not to be named. ‘Yes’, she said, ‘calories do seem to be slipping off the nutrition labels’. Mentioning she is 50 years old and used to calories, she said of the kJ numbers: ‘I can't do anything with that – I have to get my calculator out’.

In Australia, Marion Nestle is known as the Rosemary Stanton of the USA. Yes, Rosemary said ‘we only have kiloJoules, which nobody understands. The system is deliberately confusing. Nobody wants to tell you that your muesli bar contains 345 calories’. In her opinion, obesity in Australia has been boosted by the disappearance of the calorie. ‘The best thing we could do about obesity is to go back to calories’.

See, that was interesting, wasn't it. Roger Hughes, boss of the letters section of this journal, will welcome illumination from Australian food regulation policy pundits.

Pinochet's war on Chilean hunger

And so to my first sight of the Andes, their peaks emerged from cloud as the plane prepared to land in Santiago. In common with Christopher Hitchens and in his words: ‘I have long kept September 11 as a day of mourning, because it was on that day that Savador Allende was murdered and Chilean democracy assassinated along with him’⁹. I visited the town house of Pablo Neruda, who died, twelve days after President Allende, of indulgence, cancer and a broken heart¹⁰.

The regime of Augusto Pinochet ended in 1990, and now for some, in Neruda's words, it is ‘as if nobody died, nothing/ as if they are stones falling/ on the ground, or water on water’. But there are connections between those times then and public health nutrition now. Childhood ‘classic’ malnutrition was practically wiped out in Chile between the early 1970s and the end of the 1980s. Fernando Monckeberg, the founding director of INTA (the national institute of nutrition and food technology) was given extraordinary powers by the military junta to distribute free food to pre-school age children¹¹, work for which he has received international acclaim and awards.

So was public health nutrition cynically used to legitimise a murderous dictatorship? Or was Dr Monckeberg's work one more example of how strong government progressed Chile into Latin America's first economically and socially developed nation? Or both? Survival in the South often depends on seeing things from more than one point of view.

What's wrong with industry?

Arne Oshaug has been emailing colleagues about industry sponsorship and infiltration of nutrition congresses, for discussion at the Federation of European Nutrition Societies meeting in Paris. My opinion includes wondering why industry is not OK whereas other sources of support and influence such as governments and indeed UN agencies, which also have agenda, are apparently OK. And also why a symposium funded by ™Globo-Cola is not OK, whereas a presentation by Professor Ivan Honorarium, himself funded by Chug-a-Lug-a-Jug Inc., who also works at Translucency University whose annual report may (or may not) acknowledge truckloads of support from gut-busting food and drink and biocidal chemical manufacturers, is apparently OK. What's the diff?

It is time nutrition professionals and civil society organisations stopped brandishing bible, cross and garlic every time industry is mentioned. Instead, perhaps through the newly formed World Public Health Nutrition Association, let an audit of transnational and other major food and drink industry players be conducted. After all, if all the food and drink industry is bad, and if we all are going to practice what we preach and put our mouths where our money is (or isn't), a lot of us would starve, unless we take to growing our grub in our gardens.

It also seems to me that, deeper down, relationships between nutrition scientists and the food manufacturing industry are somewhat murky. Take Nestlé, and colleagues who work with Nestlé. In Hobart I hoovered up five bookettes and two reports from the Nestlé stand. These are the products of workshops 42, 46, 47 and 50 of the Nestlé Nutrition Pediatric Program. An accompanying flyer says that the Nestlé Nutrition Institute™ has to date held over 70 workshops since 1981, and has produced over 3000 publications for health professionals since its foundation in 1960¹². A photograph in the flyer shows a woman in a white coat addressing the 58th workshop held in Ho Chi Minh City. I await a graph of upturned uptake trends of Nestlé formula feeds and kiddie-gunk in Vietnam.

I understand that the books are circulated by Nestlé to paediatric health professionals throughout the world. The bookettes state that they are ‘information for the medical profession only’, so if you are a PhD and not an MD, no peeping. The hardback reports are published by Lippincott, so are available to anybody.

About 100 people participate at these Nestec workshops. The presented and published papers are not all obviously helpful to Nestlé. To take just one example, Ed Frongillo of Cornell emphatically supports breastfeeding and also questions the ‘fast growth equals health’ theory that has buttressed infant formula manufacturers¹³. But Nestlé has corralled so many, maybe most, of the world's paediatric nutrition heavy-hitters. It would also I think be a little naïve to suppose that contributions such as those of Ed Frongillo are bad for business. Look – a company executive may say – how respectful we are of alternative views. We even give space to that Frongillo chappie.

Nestlé's war on world hunger

I now turn to the 40th anniversary annual report of the Nestlé Foundation¹⁴, kindly sent to me by post. It is beautifully presented and the thick matt paper smells authoritative. It features many full-colour photographs of smiling African and Asian children, and baskets, butterflies, buffaloes, rocks, rice, rivers, peaks, pulses, peasants. We are transported into a world with no cities, packets, or tins.

Its publications explain that while the Foundation, set up ‘for the study of problems of nutrition in the world’, was created and funded by Nestlé in its centenary year, it is (and I quote) ‘financially and operationally independent from the company’. In his Message, Foundation president Eric Jéquier thanks Nestlé CEO Peter Brabeck for his ‘personal interest and support’.

In my opinion Nestlé should be given full credit for the Foundation. I have asked my long-standing colleague and friend Prakash Shetty why he is a member of its Council. He says that the Foundation supports nutrition training and research in Africa and Asia.

This is indeed so. The 40th anniversary report contains tributes from Dr Jéquier, Jo Hautvast, Joop van Raaij, Jehan-Francois Desjeux, Mehari Gebre-Medhin and Roger Whitehead (present and past members of the Council), as well as from Prakash; and from other grant-holders and well-wishers including Jama Hamadani (Bangladesh), Jian Zhang (China), Joyce Kikafunda (Uganda), Dien Le (Vietnam), Drupadi Dillon (Indonesia), Anna Lartey (Ghana), Anura Kurpad (India), John Waterlow (UK), Kathryn Dewey (USA), Salimata Wade (Sénégal), Noel Solomons (Guatemala), Tola Atinmo (Nigeria), Sally Grantham-McGregor (UK), Nevin Scrimshaw (USA), Romain Dossa (Benin), Suttilak Smitasiri (Thailand) and Lucie Malaba (Zimbabwe).

In his tribute John Waterlow regrets that he was not able to join the Foundation Council because, at the time, he was a member of an advisory council of the Nestlé company ‘in the hope of influencing their policy on infant foods’. Kay Dewey says the Foundation is ‘one of the few organizations … that funds research on key nutrition issues relevant to developing countries’. Lucie Malaba praises the Foundation ‘for 40 years of empowering developing nations in finding solutions … to nutrition of the underprivileged’.

Prakash reveals that the research that informed the new UN recommendations for energy requirements of infants and children, which he oversaw when a chief at the FAO, ‘was also largely attributable to support provided by the Foundation for studies of human energy metabolism in several developing countries’. On energy and protein metabolism in general he says: ‘It may be well-nigh impossible to describe fully the crucial role the Nestlé Foundation has played in our current knowledge in this important area of nutrition over the 40 years since it was founded’.

Does this show that the health and welfare of the world's children is safeguarded by research selflessly funded by an independent authoritative civil society organisation? Or does it show that UN recommendations on energy and protein requirements still remain influenced by the research of selected scientists who have taken the Nestlé shilling, and whose views generally harmonise with Nestlé corporate policies? Or both?

The International Breastfeeding Action Network might point to the policy of invaders of impoverished countries, who first drop bombs, then drop food parcels. The US State Department and the US Agency for International Development come to mind as an analogy. Is this just? I certainly think we had better get wiser to the ways the world wags before we start focusing on sponsorship of congress seminars which, it now seems to me, is rather like bitching about the biscuits handed out by the international aid industry being stale. I think these issues should be ventilated in the letters column of this journal. Roger and I pause, for replies.

Acknowledgements

Sources of funding

My accommodation in Hobart was paid by the DAA, and in Santiago by the University of Chile (INTA); and flights to and from Australia, with a stop-over in Chile, were paid by DAA, whose conference corporate partners included Kellogg's, Nestlé, the Meat and Livestock Commission, Unilever, Fonterra Dairy for Life, Nutricia, Novartis and Dairy Australia, with specific events supported by McDonald's, Cadbury Schweppes, Coca-Cola and (I like it!) Nuts for Life. Thanks to all.

Conflicts of Interest

None

Authorship responsibilities

None